Cognitive-behavioral therapy is the most popular and commonly used therapy for depression treatment. Hundreds of research studies have been conducted which verify its safety and effectiveness in treating this disorder. Modern cognitive behavioral therapy (CBT) was developed independently by two separate individuals: Aaron Beck, a psychiatrist, and Albert Ellis, a clinical psychologist. Both Beck and Ellis began working on their versions of the therapy in and around the late 1950s and early 60s. Both versions of the therapy are founded on the single basic idea that cognition, in the form of thoughts and preconceived judgments, precedes and determines people's emotional responses. In other words, what people think about an event that has occurred determines how they will feel about that event. Depression happens because people develop a disposition to view situations and circumstances in habitually negative and biased ways, leading them to habitually experience negative feelings and emotions as a result.
Cognitive behavioral therapy (CBT) is a brief treatment for depression that involves two main types of strategies – cognitive and behavioral. Cognitive therapy s designed to teach individuals to (1) identify depressive patterns of thinking, and (2) replace negative thinking with more realistic interpretations, predictions, and assumptions. Through cognitive therapy, people are taught to not automatically assume their beliefs are true, but rather to challenge their thoughts by examining the evidence supporting and contradicting their negative beliefs. By broadening one’s perspective and shifting one’s thinking, cognitive therapy can be an effective tool for combating depression.
Another group of strategies that are used in CBT are more behavioral in nature. These involve changing depression by changing the patients’ behavior. One behavioral technique, known as behavioral activation, involves forcing yourself to do things even though you lack the interest, energy, or motivation. For example, you might go to a party even though you are feeling too tired and you are convinced you will not enjoy yourself. Or, despite feeling overwhelmed with the idea of applying for a new job, you might still prepare a new resume and send it out. More often than not, forcing yourself to confront a situation instead of avoiding it leads to more enjoyment than you might expect, as well as other benefits.
CBT is a relatively brief form of treatment, lasting from ten to twelve sessions. Therapy begins by establishing a supportive environment for the patient. Educating the patient about how depression may be caused by cognitive distortions is the next step. The types of faulty thinking are discussed (e.g., "all or nothing thinking," "misattribution of blame," "overgeneralization," etc.) and the patient is encouraged to begin noting his or her thoughts as they occur throughout the day. This is done so that the individual may understand how common and often these thoughts are occurring.
In cognitive-behavioral therapy, emphasis is placed on discussing the thoughts and the behaviors associated with depression rather than the emotions themselves. The rationale for this is that it is believed that by changing thoughts and behaviors the emotions will also change. Because of this approach, cognitive-behavioral therapy is short-term (usually under two dozen sessions) and works best for people experiencing a quite a bit of distress related to their depression. Individuals who are able to approach a problem from a unique perspective and who are more cognitively-oriented will to do best with this approach.
Note that for mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence. Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.
CBT differs from traditional talking therapy in several respects.
- Length. Unlike with psychoanalysis, which can last for years, the average number of CBT sessions is 12. The length of the therapy is often determined in advance, at the beginning of treatment.
- Structure. Most CBT therapists have a "lesson plan" for each session that includes a set of specific techniques and goals for the patient to learn.
- Homework. More so than other forms of therapy, CBT requires the patient to actively identify the triggers of their negative thinking and to "practice" alternative responses. Patients may be asked to keep a journal of their thoughts or to actively schedule challenging situations for themselves.
Cognitive Factors in Depression
Self-evaluation
Self-evaluation is a process that is ongoing. Therapists evaluate how we are managing life tasks, and evaluate whether we are doing what we should, saying what we should, or acting the way we should. In depression, self-evaluation is generally negative and critical. When a mistake occurs, we think, "I messed up. I'm no good at anything. It's my fault things went wrong." When someone is depressed, he/she tends to take responsibility for everything that goes wrong, and tends to give others credit for things that turn out fine. A psychologist assumes that self-evaluation, in depressed individuals, is too critical, and feeds low self-esteem and a sense of failure.
Identification of Skill Deficits Sometimes a depressed person may accurately identify a skill deficit. "I'm not good at telling people what I want from them." This is usually coupled with negative self-evaluation, "therefore, it's my fault that I didn't get what I want." However, in depression, the person assumes that he/she cannot learn how to do what is necessary to achieve a better outcome. The depressed person believes that he/she cannot learn how to act differently. Accurate identification of social skill deficits complicates depression, because it provides a reality base for the other irrational and exaggerated negative perceptions of the depressed person. If the skill deficit is real, then the depressed person assumes that all of the other negative self-assessments must be real too.
Further, when depressed, a person is more likely to identify negative characteristics of self, and less likely to see the positive. The result is a long list of the "things I cannot do," or "tasks I'm no good at," or "mistakes I've made." Psychologists help depressed persons identify their social skill deficits, and also help them develop a plan to improve those skills. This part of cognitive therapy is more behavioral, as the psychologist teaches the depressed person how to manage their life problems better.
Evaluation of Life Experiences When depressed, a person will focus on minor negative aspects of what was otherwise a positive life experience. For example, after a vacation at the beach, the depressed person will remember the one day it rained, rather than the six days of sunshine. If anything goes wrong, the depressed person evaluates the entire experience as a failure, or as a negative life experience. As a result, memories are almost always negative.
This is reflective of unrealistic expectations. Nothing in life ever works out just as you want. If we expect perfection, we will always be disappointed. Psychologists help you to develop realistic expectations about life, and help you determine what you need versus what you want. After all, most of the things that don't work out are little things. And even when important problems develop, we can either resolve the problem, or regroup, recover, and start again, with hope for a better future. In depression, the hope is missing.
Self-talk is a way of describing all the things we say to ourselves all day long as we confront obstacles, make decisions, and resolve problems. Self-talk is not "talking to yourself" in a literal sense, although it sometimes does involve talking out loud (depending on the person). There is a myth, that when you talk to yourself, it is a sign of "craziness" or mental illness. That idea stems from the "voices" or auditory hallucinations experienced in severe forms of mental illness, such as schizophrenia. When a person hears voices, he/she thinks it is someone else talking to them. The self-talk we are describing here is not like that at all. We all engage in self-talk.
Usually, it is part of our thinking process, or what we call "stream of consciousness." As we are presented with problems, or decisions, we might think, "Okay, how do I handle this?' or "This looks like it is difficult, I better ask for help." or "I know how to fix this!"
Self-talk is not bad, or wrong, or a sign of psychological problems. It is normal. But, negative self-talk prevents us from solving problems, and can contribute to a variety of psychological problems, including depression. When faced with a problem, if our self-talk is negative, it can immobilize us. "I can't do this, I'm just going to foul it up again" or "I'll probably get fired after they see how incompetent I am." Psychologists help depressed individuals identify negative self-talk, and also teach them how to challenge these negative statements, and how to replace them with positive self-talk.
Automatic thoughts
Automatic thoughts are repetitive, automatic self-statements that we always say to ourselves in certain situations. They can be positive or negative. Psychological problems develop when our automatic thoughts are consistently negative. They are automatic, because they are not the result of an analysis of the problem, they are a "knee-jerk" reaction to specific situations. For example, in social situations, do you always presume the other person dislikes you, or thinks you are stupid? When automatic thoughts control our emotional response to people, problems, and events, we ignore evidence that contradicts the automatic thought. If we cannot ignore it, we explain the evidence in terms of the automatic thought.
For example, if we talk to someone and they smile, they are really laughing at us, rather than being pleased to see us. The automatic thoughts create an expectancy of something negative. Since many things in life are vague, and can be interpreted in many ways, we learn how to negatively evaluate the world, so it agrees with our negative automatic thoughts. Psychologists help you to identify your negative automatic thoughts, and how to develop positive challenges to those negative ideas.
Irrational Ideas and Beliefs Albert Ellis first presented the idea that irrational beliefs are at the core of most psychological problems. We could also call these beliefs unrealistic, incorrect, or maladaptive. Psychologists have also suggested that these ideas are irrational because they are not logical, or are based on false assumptions. Some examples of irrational beliefs:
§ I cannot be happy unless everyone likes me.
§ If I do what is expected of me, my life will be wonderful.
§ Bad things don't happen to good people.
§ Good things don't happen to bad people.
§ In the end, bad people will always get punished.
§ If I am intelligent (or work hard), I will be successful.
What makes these ideas irrational, or maladaptive, is the belief that they are always correct. Sure, working hard will increase your chances for success, but success is not guaranteed. But, there are times when we do everything right, and we still don't get what we want. For some people, this leads to the conclusion that they are lazy, no good, incompetent, or weak. The result is a loss of self-esteem, and sometimes, depression. Psychologists help you to identify your irrational ideas, and also how to evaluate which ideas are irrational and which are not. Finally, the ideas need to be changed to reflect the real world.
Overgeneralizing or Catastrophizing Catastrophizing is a negative overgeneralization. It is "making a mountain out of a mole hill!" For example:
- One person at work does not like you, and tells you, so you know it's not mistaken judgment. You then assume no one at work likes you, or you assume that you must be a terrible person if he/she does not like you.
- You make a small mistake on a project, and assume that you will be fired when the boss finds out.
- You try your hand at a new hobby, and it does not turn out well. You conclude, "I'm no good at anything."
We all make mistakes. If you overgeneralize one, or even a few mistakes, to the conclusion that you are bad, incompetent, or useless, you might become depressed. Psychologists help you identify and change negative overgeneralizations.
Cognitive distortions are another way of describing the irrational ideas, overgeneralizing of simple mistakes, or developing false assumptions about what other people think about us, or expect from us. We are distorting reality by the way we are evaluating a situation. The concept of cognitive distortion highlights the importance of perceptions, assumptions and judgments in coping with the world. Psychologists help us determine what evaluations are distortions by providing objective feedback about our evaluations of the world, and by teaching us how to change the way we perceive problems.
Pessimistic thinking does not cause depression, but it appears to be easier to become depressed if you tend to view the world with considerable pessimism. After all, pessimism is a tendency to think that things won't work out as you wish, that you won't get what you want. Pessimism feeds the negative cognitive distortions and self-talk. On the other hand, optimism appears to create some protection from depression.
Hopelessness is a central feature of depression, along with helplessness. If you view your world as bad, filled with problems, and don't think you can do anything about the problems, you will feel helpless. If you don't believe your life will improve, if you think the future is bleak, then you will begin to feel hopeless. Pessimism encourages these negative assessments of your life. Optimism prevents you from reaching those conclusions. In fact, psychologists have researched ways to learn how to be more optimistic, as a way of fighting depression.
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