The Ethical Treatment of Depression: Autonomy through Psychotherapy

5. Understanding Negative Biases Promotes Autonomy in Depression

In the previous chapter, I argued that a number of factors conspire against the exercise of autonomy by people with depression. I showed that negative biases breed a pessimism, with doubtful warrant, that pervades judgments about important life events. I also argued biological beliefs about depression causation to be prominent in Western society, likely resulting from a dominant medical view that depression is “brain based,” in concert with the widespread prescription of ADM. I showed such beliefs to be, in the main, unjustified and to work against the material understanding of psychosocial stressors as causal in depression. I also argued that, even when stressors are identified, negative attributional style can thwart their accurate appraisal. I concluded that a primary source of the autonomy impairment in depression is a failure to hold justified beliefs about the poor evidential value of affect. An understanding that depressed affect skews appraisals is a prerequisite for the systematic evaluation of triggering life events. It is this kind of empirical analysis that is most likely to lead to justified beliefs about material facts in the setting of a worldview that is permeated with negative affective bias. Now, I want to determine how autonomy impairment in depression is addressed by its two principal, validated treatments, CBT and ADM. In the current chapter, I investigate how each treatment deals with negative information-processing biases, and in the next chapter I focus on how each addresses the psychosocial stressors that can trigger depression. CBT and ADM both counter negative biases, but two differences in the way these treatments “debias” depressive pessimism permit a moral demarcation between them. First, CBT requires the depressed individual to understand the action of negative biases. Through mindfulness, and the related skill metacognitive awareness, cognitions primed by negative affect are viewed with detached skepticism until confirmed or refuted by empirical investigation. A prerequisite of this approach is acceptance of the poor Understanding Negative Biases Promotes Autonomy in Depression 5 98 Chapter 5 evidential value of negative affect in depression. The therapeutic effect of ADM requires no similar kind of comprehension. Given the materiality of justified beliefs about the poor evidence afforded by depressed affect, I argue that CBT confers a prima facie autonomy advantage. However, there is a second point of difference, which derives from evidence suggesting ADM limits the amplitude of negative affective swings. I argue that negative affect retains some utility, even in depression, to mark events of material significance. Despite depression’s status as a disorder, its constituent affect has a residual appraisal function. The depressed person treated with ADM is, therefore, constrained in using negative affect to flag occurrences relevant to his or her interests. I argue that the CBT-treated person can, through negative affect, better identify significant events and more accurately assess them. As a result, he or she is well placed to hold justified beliefs about material facts concerning triggering events. These effects, taken together, suggest that CBT promotes the autonomy of the depressed person, not just in a different way, but also to a greater extent, than does treatment with ADM alone. To mount the argument, it is first necessary to understand what is known of the therapeutic mechanism of CBT in depression. 5.1 Mode of Action of Psychotherapy in Depression In a widely cited definition, Hans Strupp has proposed the psychotherapeutic intervention to be [a]n interpersonal process designed to bring about modifications of feelings, cognitions, attitudes and behaviour which have proved troublesome to the person seeking help from a trained professional.1 Of more than four hundred types of psychotherapy identified,2 only a handful has been shown to benefit depression in controlled trials. The most extensively evaluated and clearly substantiated is CBT,3 which, I will show, is an exemplar of Strupp’s definition. Other therapies that have been subject to clinical trials, with generally favorable results, include mindfulness-based cognitive therapy (MBCT)4 , IPT,5 and problem-solving therapy.6 While these treatments will not be considered in detail, the autonomy claims I make for CBT would also apply to them, should they achieve benchmark efficacy and afford the kind of knowledge I hold to be material in depression. In the previous chapter, I described the relationship between affect and cognition in depression as one of “mutual reinforcement.” If I augur Understanding Negative Biases Promotes Autonomy in Depression 99 unpleasantness, negative affect convinces me that my gloomy outlook is accurate...