CBT in the Treatment of Depression

6.1 Introduction

In this module, you will learn how CBT techniques are applied in the treatment of depression. Following a review of what depression is and how it is diagnosed, you will learn how the CBT paradigm conceptualises this illness and the interventions that work well with this client group.

What is depression?

It is normal to experience a low mood from time to time. However, someone who feels sad, low, or 'numb' for several weeks or months might be suffering from depression. Depression can manifest itself in different ways.

For instance

It is associated with sadness in
adults, but is more likely to prompt irritability and mood swings
in teenagers. Depression can be mild, moderate, or severe in nature. The
classification depends on the extent to which it is affecting the client's
day to day functioning. Depression can be triggered by a major life event
such as the death of a loved one, losing a job, losing a home, or the end
of an important relationship. In some cases, even 'positive' stress, such
as getting married or having a baby, can lead to depression. It can affect
people of any age, sex and socio-economic background. Genetics, social
factors (such as poverty and deprivation) and a history of abuse or trauma
are other potential causes. However, in many cases, it is impossible to
identify a single cause.

Fact

Around 10% of people will have at least one episode of depression at some point in their lives.

Source: www.nhs.uk

6.2 The Physical, Emotional and Psychological Aspects of Depression

Depression is classified as a mental illness, but its effects go far beyond psychological distress.

Here is a quick overview of typical symptoms:

Psychological symptoms

Feeling tearful, feeling guilt-ridden, continuous low mood or sadness, feeling hopeless and helpless, low self-esteem, feeling anxious, feeling worried, thoughts of harming oneself, thoughts of suicide, feeling irritable and intolerant, having no motivation, losing interest in activities that previously gave pleasure and enjoyment, finding it hard to make decisions.

Physical symptoms

Lack of energy, low sex drive, disturbed sleep, menstrual problems, moving or speaking more slowly than usual, changes in weight or appetite, constipation, and unexplained aches or pains.

Social symptoms

Poor performance at work or school, social withdrawal, taking part in fewer activities, and relationship difficulties.

There are several varieties of depression

Postnatal depression (PND) refers to depressive symptoms that begin shortly after giving birth. It is not yet clear what causes it, but it is likely that the huge life changes that come with having a baby, coupled with physical exhaustion and fluctuating hormones, act together to produce the symptoms.PND is treated in much the same way as 'normal' depression, via a combination of therapy and medication.

Bipolar disorder entails a mixture of depressive spells mixed in with episodes of mania. (For this reason, the disorder was formerly known as 'manic depression'). The depressive symptoms are the same as those seen in regular (unipolar) depression. Finally, Seasonal Affective Disorder (SAD) is a disorder in which depressive symptoms are limited to the winter months.

Fact

Around 4% of UK children aged five to 16 are clinically depressed or anxious.

Source: www.nhs.uk

6.3 Aaron Beck's Theory of Depression

From the list of symptoms above, it is clear that depression is a multi-faceted illness that affects a person's thoughts, feelings and behaviours. The work of Aaron Beck was ground-breaking, because it identified the precise mechanisms that maintain depression.

His Cognitive Model of Depression takes into account the following:

The cognitive triad

The tendency to think negative thoughts about oneself, the world and the future. These vary in accordance with the grade of depression. People with mild depression are somewhat discouraged about the future, those with moderate depression think that the future is likely to be unpleasant, whereas people with severe depression believe that there is no meaningful future at all. In other words, a person with depression perceives the world through a set of negative schemas.

Beck believed that an underlying theme of depression is a sense of loss. In some cases, the link might be obvious. If someone becomes depressed following the death of a loved one, the nature of the loss is obvious. If a client has become depressed following a redundancy, the cause and effect is also straightforward. However, loss can also be a factor even in cases of depression that occur following a positive event. Depression following the birth of a baby may well be triggered by hormonal changes, but it may also be related to the loss of personal independence that comes with the parental role.

Cognitive distortion

The tendency to interpret information from the outside world in a manner that results in unnecessary distress. 'Filtering' is often seen in depressed clients. They will typically hone in on one or two relatively minor negative details and blow them out of proportion, causing them to feel even worse. Another cognitive distortion is a tendency to jump to conclusions, even when these are unfounded. Someone who assumes that a friend or colleague is mad at them simply because they did not answer their telephone call is processing information through this distorted lens.

Other cognitive distortions are as follows.

Polarised thinking

Also known as 'black and white' or 'all or nothing' thinking, this translates to absolute judgements that allow for little ambiguity or shades of grey.

For example

A student who concludes that they are stupid because they received an average grade on a test is engaging in polarised thinking - because they are not perfect, they must be a failure.

Overgeneralisation

Taking one piece of information and using it to make a negative judgement; such as someone who believes that because they have failed once that they are bound to fail over and over again is engaging in overgeneralisation.

Personalisation

Taking personal responsibility for external events without good reason.

For example

Someone who sees that their boss looks irritated and automatically assumes that it is their fault is personalising the situation.

Catastrophising

A catastophiser anticipates negative outcomes and expects the worst to happen. They are likely to magnify the significance of minor events and assume that anything that can go wrong, will go wrong.

Control fallacies

This can take two forms. People who hold the irrational belief that their lives and actions are controlled by external forces (the fallacy of external control) may fail to take an appropriate level of responsibility.

For example

They may say, “I can't help it if I got angry and shouted at my partner. The neighbours were playing loud music and it made me mad!”

On the other hand, someone with a fallacy of internal control thinks that they should hold themselves accountable for the health and wellbeing of everyone else. They often ask questions like “My daughter isn't happy, what did I do wrong?” In assuming that their actions are linked to someone else's feelings, they are setting themselves up to feel depressed.

Shoulds

Everyone has their own moral code, but someone who lives their life in accordance with a long list of 'shoulds, musts and ought tos' will find themselves feeling frustrated and angry when others do not comply with these rules (even if they do not know what they are!) and guilty when they do not live up to their own standards.

Blaming

“Stop making me feel angry!” is an example of an inappropriate blame statement. It is true that external events can indirectly trigger particular feelings, but humans have the ability to think about situations in a new light and therefore control their own emotions.

Fallacy of fairness

Someone who holds onto the belief that life 'should' be fair, or that unfair situations can always be corrected, will often feel disappointed and disillusioned. Not only that, but people have their own ideas as to what constitutes 'fairness'.

Fallacy of change

People who make their own happiness contingent on someone else quickly become sad, depressed and angry when the other party does not change to fit their ideals. This belief can also keep depressed people stuck in unhealthy relationships, as they assume that one day they will be able to change the other person.

Global labelling

This describes the tendency to attach a label to a person, situation, or thing based on one or two incidents or qualities.

For instance

A person who labels themselves 'undesirable' after being turned down for a date is engaging in global labelling. Global labelling can decrease an individual's motivation to change, thus keeping them stuck in the same situation for a long time.

Emotional reasoning

This distortion is based on the assumption, “If I feel a certain way, it must be true”.

For example

If someone feels unattractive and so assumes that it must be true, they are using emotional reasoning. A client who feels as though they are destined to be depressed forever will sincerely believe it to be true.

Heaven's reward fallacy

Although life is not fair and the good do not always prosper, some people operate under the assumption that self-sacrifice and denial merit a reward in the end.

For instance

Someone who gives up an opportunity for a good job in order to move across the country to be with their partner may become depressed when the relationship ends because their 'reward' did not come through. They do not appreciate the importance of being responsible for their own happiness.

Always being right

When someone believes that it is important to be right and that to be wrong signals an underlying personal weakness that should be eradicated at all costs, they will become despondent when theym(inevitably) fail or misunderstand something. This line of thinking also undermines relationships, because the client's friends and family will soon become tired of being told why their views are incorrect or ill-informed.

The more frequently an individual allows the above distortions to colour their thinking, the more depressed they are likely to be. These distortions can also be a barrier to treatment.

For instance

Someone who is depressed is likely to think that the future is bleak and that they cannot reasonably hope to get better. CBT practitioners need to anticipate in advance the challenges they will come up against when working with a depressed client.

Activity: Personalisation

Estimated time: 5 minutes

Imagine that you are working with a client who has a habit of personalising situations. They ask you to explain why personalisation makes depression worse.

What would you say?

6.4 Albert Ellis' Theory of Depression

Albert Ellis' work focused on core irrational beliefs. These beliefs make someone vulnerable to experiencing a low mood and adopting a negative outlook towards life in general. They are often acquired early in life and cause problems until they are addressed and challenged.

Specifically, Ellis believed that there are three irrational beliefs frequently seen in depressed clients, which are as follows:

“I must be completely competent in everything I do, or I am worthless.”

“The world should always grant me happiness, or else I will die.”

“Other people must treat me with consideration, or they are terrible people.”

When someone thinks along these lines, they are placing themselves and other people under great pressure. These unrealistic expectations set them up for disappointment. They may start to believe that no one can meet their needs and that the world is out to get them. Needless to say, these beliefs promote depressive thinking. Like Aaron Beck, Ellis believed that it was also important to look at cognitive distortions that depressed clients use to support their bleak views of the world. His preferred approach was to prompt a client to evaluate the evidence for and against a belief and ask them questions about what life would be like if they were to relinquish it.

6.5 The Role of Formulation

In Module 4, you learned how therapists carry out formulations in order to understand the nature and causes of a client's issues. CBT practitioners distinguish between the original cause of the problem and the factors that keep it going.

For example

Suppose a client's mother died suddenly and, from that moment onwards, they began to experience symptoms of depression that went beyond healthy grief. In this case, the original cause of the depression is clear. However, the maintaining factors may not be apparent on first glance. Only through talking to the client and observing their thought processes can a therapist make progress.

For instance

It may transpire that the client operates under the assumption that life 'should' be fair. Viewing the situation with this information in mind, it becomes clear that the client's worldview and most cherished assumptions have been dealt a blow following this experience.

6.6 The CBT Interventions That Help Alleviate Depression

Psychoeducation

Clients with depression tend to feel as though there is no hope for the future and that they are destined to be depressed forever. Explaining the mechanisms of depression in terms of the biological and psychological factors that contribute to the illness can offer the client a sense of hope for the future. The depth of explanation can be adjusted to suit the client's personality and cognitive functioning. It may be sufficient to state that 'the purpose of CBT is to learn new ways of thinking and acting, so that your mood will improve'.

Mood monitoring

Mood monitoring is a key homework task for clients with depression. Clients may be asked to keep a diary of their average mood (for instance, on a scale of 1-10) for a week and to fill in a worksheet that captures what (or who) triggers changes in mood. This data

helps both client and therapist establish the severity of a client's problem and to hone in on vicious cycles, maladaptive coping mechanisms and triggers.

Mood monitoring will also reveal to the client that their mood is seldom flat all the time. It is true that most people with depression feel low much of the time, but there is still room for fluctuation. Completing a mood diary can provide a client with proof that they do have the capacity to feel 'OK' at least occasionally.

Behavioural activation

People with depression report that they have little interest in social activities and no motivation to engage in hobbies that previously brought them pleasure. They fall into a vicious circle - because they do not do anything that brings them pleasure, they feel bad about themselves and their life, which further saps their motivation and so forth. 

Behavioural activation is an effective, short-term coping strategy that can have a significant effect on your client's mood. During depression, we are less likely to indulge in the activities that we like and tend to withdraw from the world in general. Behavioural activation is designed reinforce the client's contact with rewarding activities that are consistent with their core values.

Tips to enhance the effects of behavioural activation

Identify activities that are important to the client: Many times, people have a tendency to indulge in activities that they 'should' be doing as opposed to what they really want to do. Talk to your client and find out what really feels pleasurable to them as they need to feel connected

to the activity that you're suggesting. Ensure that the activities you choose together are specific and measurable: If the client enjoys organising their home, ask them if they want to organise their kitchen in the next three days. Ask them to record their time and feelings while doing the task.

Choose easy activities to begin with and work with a variety of activities: Start out by assigning easy activities so that the client doesn't feel overwhelmed. Also. Select activities across different areas of life such as education, work, home, family and friends, volunteering and travel etc. Encourage clients to be mindful: It's possible to be stuck in our heads even while we indulge in pleasurable activities. Motivate clients to engage with the present moment and enjoy their activity with their full awareness.

Behavioural activation encourages the client to focus on the things they previously enjoyed and scheduling positive activities. A depressed client will typically be reluctant to schedule activities at first. They might feel as though they will not have enough energy to follow through with their plans, that they will not derive any pleasure from them anyway, or both. However, depression responds well to positive, structured activities.

A CBT therapist will tell the client that although they may not feel the urge to take part in an activity, this does not mean that it will not offer any benefit once they get started. “Fake it 'til you make it” is a useful mantra in these cases.

Cognitive restructuring

Living under the burden of negative core beliefs and a negative self-schema perpetuates depression and results in a bleak outlook that makes recovery difficult. Guided by Ellis' work, modern CBT provides clients with space in which they can locate their core beliefs, evaluate them and then work on substituting them with more constructive alternatives.

For instance

A client may have learned as a young child that their worth as a human being depended on achieving high grades at school. If their parents only demonstrated a significant level of love, attention and approval when the child earned an outstanding report, they are likely to adopt the assumption that if they do not consistently succeed at something, they are not worthy of love and attention.

As an adult, the child will then assume that they have no intrinsic worth as a person if they receive a negative performance review at work, fail a driving test, or even fail to make significant progress in a hobby. A single core belief can have a strong impact on an individual's life.

Challenging cognitive distortion

A depressed client will usually realise that their thinking styles are unhelpful, but when they are taught to identify specific distortions they can feel empowered as a result. Most clients will feel overwhelmed by a lengthy sheet of all the cognitive distortions that characterise depression, but the majority respond well if they are given information about the most common forms and asked to identify examples in their everyday life.

For instance

A client who is told that depressed people tend to discount the positives and fix on minor inconveniences can then be tasked with noticing when they engage in this distortion between therapy sessions. The client can then move on to the next step - committing to changing these habits where possible.

Exercises that encourage evidence-gathering

Clients are encouraged to adopt the role of a detective or objective observer and ascertain whether their assumptions about themselves, the world and other people are really true.

For instance

If they assume that a friend has failed to respond to a text message because they are angry (i.e. the client has jumped to conclusions), they could decide to identify evidence against this assumption. Perhaps their friend has set their phone to silent because they need to concentrate, or maybe they intended to reply but were then distracted by something else. Keeping a diary of events and thoughts helps a client understand that their personal interpretations, rather than outside events, are responsible for the majority of their distress.

ANTS

As they progress through therapy, clients may be alarmed to discover that their negative thought processes occur outside of their conscious control. In CBT parlance, these are known as 'automatic negative thoughts' (ANTS). ANTS can be unnerving, but a client can learn to recognise these thoughts before letting them go. A key lesson clients learn during CBT is that just because a thought arises does not mean that it is true or that it demands immediate action.

Activity: A Behavioural Experiment For A Depressed Client

Estimated time: 5+ minutes

Imagine that you are treating a depressed client who claims that they have no motivation to take part in their former hobbies and interests. They tell you that they used to be a keen gardener, but have not ventured beyond the back door for a few months.

How could you use this information as the basis for a behavioural experiment?

Module Summary

Depression is a relatively common mental illness that is characterised predominantly by a low mood that lasts for weeks, months, or even years. Other symptoms include restlessness, irritability and physical complaints such as vague aches and pains. In the CBT paradigm, depression comprises unhelpful, negative thought patterns and perspectives, negative feelings and maladaptive behaviours. It can develop following a critical event, but it can also worsen gradually over months or years until an individual realises that their mood is having a

devastating impact on their life.

There are several types of depression, including PND, SAD and the depressed phases seen in bipolar disorder. Depression usually responds well to CBT treatment. Effective interventions include cognitive restructuring, behavioural experiments, behavioural activation, visualisation and mindfulness. By definition, depressed people typically have a negative outlook on the future and life in general.

They may be sceptical that CBT can 'work' for them and therapists should expect to be met with resistance, particularly in the early stages. Psychoeducation, patience and an emphasis on practical experiments and exercises can all lower resistance to treatment. However, provided that a depressed client is willing to engage with the treatment, they are likely to start re-engaging with life and see an improvement in their mood.