Bottonari et al (2008) present another interesting contribution to the question of whether Behavioral Activation (BA) is superior to Cognitive Therapy (CT) in a single-case study they present in Cognitive and Behavioral Practice. A 62-year-old man seeking treatment for chronic, treatment-resistant depression and comorbid personality pathology received 21 sessions of CT, which was ineffective, then the therapist switched to an equal amount of BA, which was effective. That shows that BA is better than CT, right?

The therapist was a grad student in her second year of practicum training. She had training in individual and group CBT for depression and had a supervisor with expertise in empirically-supported treatments. She began CT by working to help the client "identify, track, and evaluate his dysfunctional cognitions" and there also was "a lesser focus on increasing pleasant activities in order to challenge dysfunctional beliefs." Even though an agenda was set for each session, the discussion often strayed from the topic despite the therapist's efforts to redirect Mr. X back to the agenda. "Discussions were interrupted by Mr. X's long stories about his life and his thoughts about God's role in his depression with subsequent crying spells." When the therapist focused on Mr. X's negative cognitions, "his mood spiraled down in response to the content of his thoughts." He also "repeatedly denied memory of the material discussed in prior sessions and stated that he had forgotten to monitor thoughts between sessions."

As I think about the article's description of how CT was implemented, a number of thoughts occur to me:

1. From the beginning of treatment, the focus was on monitoring and challenging dysfunctional thoughts. With a seriously depressed client, Beck recommends an emphasis on behavioral interventions until there is some improvement in the client's mood.
2. When attempts were made on behavioral interventions, the emphasis was on increasing pleasant activities rather than on identifying activities that improved the client's mood and working to increase those activities.
3. The client's noncompliance (both within the session and between sessions) does not appear to have been addressed effectively.
4. The client was prone to depressive rumination. "Rational responses" often are ineffective or counterproductive in dealing with rumination. Despite the observation that the client had difficulty using cognitive restructuring effectively between sessions, the therapist persisted with this approach rather than trying other ways of dealing with rumination.
5. While the impact of comorbid dependent personality traits is mentioned, there is no mention of any attempt to address these traits (even though the authors cite at least one reference that has a detailed discussion of CT with dependent personality disorder).
6. The client reported that he was unable to remember what had been covered in previous sessions but there is no mention of any steps to address problem (i.e. summarizing the major points that were covered at the end of the session, providing the client with a written summary or supplemental readings, using written forms such as Greenberger and Padesky's "Action Plan" form and the "Behavioral Experiment" form, etc.).
7. There is no mention of attempts to address the client's avoidance

When the therapist finally switched to BA "Mr. X was encouraged to look at his daily behaviors and to observe differences between times when he was engaged in pleasant activities and times when he was inactive and/or ruminating on negative themes." He began to get up earlier, participate in planned activities, and participate in new activities. This is exactly what CT should have started with given Mr. X's level of depression! Cognitive interventions should have been introduced after "Activity Scheduling." When the therapist did address Mr.X's negative thinking when trying a BA approach "rather than challenging the content of his thoughts, the therapist asked him how his ruminative thinking influenced his mood and had him consider engagement in negative thinking as a chosen behavior." This is a much more promising way of dealing with rumination than the therapist tried when attempting CT. It is an approach often used in CT (I don't remember if Beck discusses it but I believe that Burns does).

In short, I think that the therapist did better CT when she was attempting BA than she did when she was attempting CT. I don't intend any disrespect towards BA, I think BA is a promising approach. However, it seems as though CT's biggest problem is that therapists are trying to do CT without knowing how to do it well. If the client is seriously depressed, don't start with cognitive restructuring, start with activity scheduling and introduce cognitive interventions once the client's mood begins improving. If attempts at "cognitive restructuring" make the client's mood worse rather than better, don't perseverate for weeks, try one of the alternative approaches. If there are comorbid conditions that complicate treatment, address them rather than trying to plow ahead despite the complications.

Bottonari, K.A., Roberts, J. E., Thomas, S. N., & Read, J. P. (2008) Stop thinking and start doing: Switching from Cognitive Therapy to Behavioral activation in a case of chronic treatment-resistant depression. Cognitive and Behavioral Practice, 15, 376-386.