I have been invited to write a clinical article on psychotherapeutic interventions for chronic depression. Rather than writing an article that only reviews the traditional cognitive behavioral analysis system of psychotherapy (CBASP) and provides outcome data, I focus primarily on an alternate approach.1-3 I discuss CBASP, but I will also describe a strategy that can be added to CBASP practice that may improve clinical outcomes.
My discussion is informed in large part by contemporary learning theory (CLT) and, more specifically, by Prof Mark E. Bouton4 of the University of Vermont who published a splendid book in 2007 reviewing the synthesis that has taken place in the psychological learning laboratories. This is a learning theory revolution of which few psychiatrists and clinical psychologists are aware. Bouton describes how the cognitive revolution in psychology during the late 1960s, 1970s, and 1980s invaded the learning laboratories. The cognitive construct prompted researchers to study an expanded view of human and animal functioning when investigating behavior. The cognitive revolution subsequently thrust Pavlovian5 and Skinnerian6 learning into complementary positions.
One can no longer infer the presence of one type of learning (eg, Pavlovian learning) in the psychotherapeutic or pharmacotherapeutic context without implicating Skinnerian learning. For more than 7 decades, the 2 learning processes were dichotomized and conceptualized as mutually exclusive. The upshot of Bouton’s synthesizing view, which has significant ramifications for patient practice, is that metaphorically, Pavlov and Skinner are both sitting on the shoulders of all mental health practitioners who administer psychotherapy and/or pharmacotherapy.
The Bouton synthesis
Bouton’s synthesizing approach to Pavlovian and Skinnerian learning assumes that both models almost always interact to help organisms (1) learn about the stimulus properties of the interpersonal environment in which they live (Pavlov) and (2) learn to adapt to the interpersonal environment to obtain needed reinforcers (Skinner). Both learning processes must be concomitantly operative if humans (and animals) are to survive the environmental challenge.
Figure 1 illustrates Bouton’s synthesis of the learning processes in a basic paradigm.4
For the first time in the history of psychology and psychiatry, an adequate theory of learning is now available to practitioners to describe the following in CLT terminology:
- The etiology, diagnosis, and psychosocial functioning of chronically depressed patients.
- The learning goals of treatment and a way to assess the impact of learning on treatment outcome.
- What clinicians are trying to teach patients, defined as the “subject matter” of therapy.
- The prevention of the loss of extinction of the older pathological learning during the posttreatment period.
To date, the absence of an adequate learning theory has precluded clinicians from using learning theory to inform and describe the many activities that constitute psychological and psychiatric practice.
Any interpersonal stimulus situation, S:CS (conditional stimulus) that is followed by a biologically significant event, that is a reinforcer, S*:UCS (unconditional stimulus: pleasure, physical or psychological pain, fear, anxiety, hunger, thirst, and sexual satisfaction or deprivation) presents a learning moment in which the S*:UCS becomes associated with some behavior (response) and also with contextual cues or occasion setters.4,7 The cues may be a place (eg, office, waiting room, workplace, home) or the context may involve particular individuals (eg, parent or caregiver, spouse, therapist, work colleagues, teacher, friend). In addition to being directly associated with S*:UCS, these originally neutral context cues can also become occasion setters that signal the availability of reinforcement if certain responses are made.
An example is seen in early childhood abuse when a parent (S:CS) repeatedly berates or physically abuses a child for breaking the rules. The child experiences fear/anxiety (because S:CS activates S*:UCS (fear/ anxiety) whenever he or she is around this significant other (who has now accrued conditional stimulus valence or excitor stimulus value). Active physical avoidance of contact with this parent, which is a response in the presence of the feared parent (S:CS), enables the child to decrease the fear/ anxiety (S*:UCS) and keeps it under control.
As shown in Figure 1, being in the presence of the abusing parent (S:CS) becomes an occasion setter and denotes that a response
The Pavlovian variables that interest most clinicians are the patient’s emotional responses (past, present, and emotional reactions to anticipated future events), motivation to change, and the memory of previously learned associations (both short- and long-term memory). The Skinnerian variables we focus on in treatment are behavior and the reinforcers that behavior elicits.
CLT applied to clinical practice
CLT can add something that has been missing in our practice efforts. It will enable us to do more than just expose patients to psychological techniques and medicines and then observe the outcomes. Once patient learning concerns are added to practice, the clinician can address some important case management issues that may have been overlooked. For example, the following practice question moves to the forefront: what are patients learning from us psychologically?
This question implicates both psychotherapy as well as pharmacotherapy. CLT nudges us to ask the following specific questions: What are we trying to teach patients with our treatment? How much of the subject matter have patients learned? How does the learning affect treatment outcome and beyond?7,8 Answering the first part of the last question is beyond the scope of this article; however, the other questions will be briefly addressed.
Some psychologists and psychiatrists may not see an immediate connection between CLT and pharma-cotherapeutic practice. However, pharmaco-therapy can provide a learning opportunity in which the drug (S:CS) evokes positive feelings (S*:UCS) in the patient. Biological treatment of patients with medication is pure Pavlovian conditioning accompanied with a strong Skinnerian component.5,6 Think of it this way: I learn that taking (response) a particular antidepressant pill (S:CS) makes me feel better (S*UCS: Pavlov); the pill (S:CS) is itself associated with feeling better (S*:UCS). I also adhere to the medication regimen (response) because I have associated feeling better with taking a pill (response→S*:UCS association: Skinner).
In pharmacotherapeutic practice, compliance responses are critically important for patients. In addition, other neutral conditional stimuli (occasion setters, ie, place and person contextual cues such as the practitioner, his receptionist, the practitioner’s office, partner, children, friends) become associated with pill-taking to feel better (again, response→S*:UCS association). Furthermore, terminating the medication with the withdrawal of the associated S*:UCS at the end of treatment automatically places patients in an extinction trial/phase—many of the S:CSs are still present but are now encountered without the S*:UCS.
Without being aware of the dangers of the loss of extinction of the older psychopathological patterns (which are typically not erased in the brain), practitioners may have a serious relapse or recurrence problem during posttreatment. Relapse and recurrence are nonlearning labels that simply denote the loss of extinction of psychopathology following successful treatment. CLT alerts us to the importance of preserving the continued extinction of the older malevolent patterns.
1. McCullough JP Jr. Treatment for Chronic Depression: CBASP. New York: Guilford; 2000.
2. Keller MB, McCullough JP Jr, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med. 2000;342:1462-1470.
3. Klein DN, Santiago DJ, Vivian D, et al. Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression. J Consult Clin Psychol. 2004;72:681-688.
4. Bouton ME. Learning and Behavior: A Contemporary Synthesis. Sunderland, MA: Sinauer Associates; 2007.
5. Pavlov I. Conditioned Reflexes. Anrep GV, trans. New York: Dover Publications; 1927/1960.
6. Skinner BF. Science and Human Behavior. New York: The Free Press; 1953.
7. Bouton ME. Context, ambiguity, and unlearning: sources of relapse after behavioral extinction. Biol Psychiatry. 2002;52:976-986.
8. Manber R, Arnow B, Blasey C, et al. Patient’s therapeutic skill acquisition and response to psychotherapy, alone or in combination with medication. Psychol Med. 2003;33:693-702.
9. Foa EB, Meadows EA. Psychosocial treatments for posttraumatic stress disorder: a critical review. Annu Rev Psychol. 1997;48:449-480.
10. Horowitz MJ. Stress Response Syndromes. London: Jason Aronson; 1986:chap 5.
11. McCullough JP Jr. Treating Chronic Depression With Disciplined Personal Involvement: CBASP. New York: Springer; 2006.
12. Thase ME. Long-term treatments of recurrent depressive disorders. J Clin Psychiatry. 1992;53 (suppl):32-44.