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Cognitive Behavioral Therapy for Major Depression Continued

Rashmi Nemade, Ph.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

A more concrete example of how CBT works may help. A therapist using Albert Ellis' techniques will help a depressed person to understand the chain of events that leads them to become depressed in terms of multiple steps occurring in sequence. For ease of remembering, these steps are identified by the first letters of the alphabet: A, B, C, D, and E.

In Ellis' scheme the "A" stands for Activating experiences, such as interpersonal relationship problems, work stresses or dissatisfaction, memories of early childhood traumas, and other situations that a person views as immediate sources of unhappiness. The "B" stands for the irrational, self-defeating Beliefs that are causing someone's unhappiness. The "C" stands for Consequences, which are the depressive symptoms and negative emotions that result from unhelpful beliefs. Although the activating experiences may have been traumatic or painful, the cognitive therapist will point out that people's irrational beliefs actually create their depressed mood. In other words, it is people's reactions to situations, rather than the situations themselves, that cause problems. During therapy sessions, cognitive therapists will teach patients how to Dispute (e.g., the "D" step) the irrational beliefs, so that they may develop positive psychological Effects (the "E" step) of rational beliefs. Though the above ABCDE scheme is due to Ellis, a therapist working according to Aaron Beck's version of CBT would teach essentially the same procedure.

Cognitive behavioral therapists teach their patients to identify debate and then correct their irrational ideas. The disputing process involves teaching patients to systematically ask and answer a set of questions designed to draw out whether particular ideas have any basis. Examples of disputing questions include:

 

     

  1. Is there any evidence for this belief?
  2. What is the evidence against this belief?
  3. What is the worst that can happen if you give up this belief?
  4. What is the best that can happen?

After multiple sessions of CBT training, patients learn to monitor their own thoughts and perform the disputing process on their own outside of therapy sessions.

To continue with our example, the cognitive therapist would take an automatic thought generated by our depressed person such as "everyone hates me", and help her to examine the basis of that thought. The therapist might ask the patient whether it is literally true that no one loves her, encourage her to list examples of people who love or like her, and point out that thinking she is completely unlovable is erroneous and therefore should not be taken seriously.

The behavioral aspect of CBT involves replacing behaviors that are contributing to patients' depression with healthier ones. CBT therapists determine whether patients' behaviors are problematic or if they appear to have skill or coping deficits. Therapists then recommend alternative behaviors as appropriate, and educate patients in missing skill sets. For example, participation in exercise, hobbies and social activities, as well as regular use of breathing, relaxation or visual imagery techniques can help decrease depression. Knowing this, a CBT therapist may encourage socialization or exercise for patients who have become withdrawn. CBT therapists may also use other techniques including role-playing (practicing new behaviors in session), prescription risk-taking activities (practicing new behaviors outside the therapy session), assertiveness training, and so on to help patients to improve.

CBT patients are prescribed homework throughout the course of their therapy. Homework assignments generally consist of instructions to keep a log of thoughts, behaviors, and moods, as well as written records of their efforts towards practicing cognitive restructuring exercises. Clients also note changes that occur as they try out new thinking or behavior skills, or fall back into old thinking habits. As negative patterns become clearer, patients can experiment by trying out new skills and seeing (by looking at their logs and homework assignments) how these changes positively impact their mood.

Along with reducing the number of negative thoughts and behaviors, CBT therapists also help depressed people to learn how to break complex and seemingly insurmountable tasks into smaller, more manageable components (as doing so increases their likelihood for achieving success). For example, if cooking an entire meal seems overwhelming to a depressed person, then that depressed person might be encouraged to do whatever part of that larger task she can manage. She can, for instance, take pride in making one course of the meal on a given day. Teaching depressed people to take control of their negative anticipations and fears surrounding tasks (by disputing them or breaking them down into small manageable parts) can help decrease patients' avoidance and anxiety, and result in more rewarding success experiences which increase mood, and fuel patients' desire and self-confidence for attempting new tasks.

Cognitive behavioral therapy is offered in both individual and group formats, and in both outpatient and inpatient settings. Research-based therapy protocols typically last between 12 and 16 weeks in duration (assuming weekly therapy appointments); however, the therapy can be tailored (e.g., by increasing or decreasing the frequency and number of sessions) to fit patients' needs.

Cognitive behavioral therapy is a good fit for verbal, goal-oriented people who want short-term, symptom-focused strategies. CBT requires that people commit to monitoring and practicing skills outside the therapy session. CBT is less of a good fit for people who have trouble with metacognition (e.g., people who have difficulty thinking about their own thinking process), who are put off by Socratic-style questioning (logical debate and argument used to examine the appropriateness and validity of thoughts), who are interested in a less directive therapist, or who are unwilling to monitor their thinking, behavior, and feelings outside of therapy sessions.