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Cognitive Behavioral Therapy for Depression Continued

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

A more concrete example of how cognitive behavioral therapy (CBT) works may help. A therapist using Albert Ellis' techniques will help a person with depression 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.

person walking outsideIn Ellis' theory the "A" stands for Activating experiences, such as 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 from Ellis, a therapist working according to Aaron Beck's version of CBT would teach basically 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:

  • Is there any evidence for this belief?
  • What is the evidence against this belief?
  • What is the worst that can happen if you give up this belief?
  • What is the best that can happen?

After multiple sessions of CBT training, patients learn to monitor their own thoughts and do 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 person with depression 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. He would encourage her to list examples of people who love or like her. Then he would point out that thinking she is completely unlovable is not true and therefore should not be taken seriously.

The behavioral aspect of CBT involves replacing behaviors that are contributing to depression with healthier ones. The therapist will determine whether the patient's behaviors are the problem or if they seem to have trouble with coping or other skills. The therapist will then recommend different behaviors as more appropriate. The therapist will also teach the patient coping skills that may be missing. For example, the therapist may recommend that the patient get exercise, take up a hobby or join a social group. They may also suggest regular use of breathing, relaxation or visual imagery techniques. They may encourage hanging out with others or exercise for patients who have become withdrawn or isolated. CBT therapists may also use other techniques including role-playing (practicing new behaviors in session), having the person practice new behaviors outside the therapy session, assertiveness and communication training, and other strategies to help patients to improve.

CBT patients are given homework throughout the course of their therapy. Homework assignments usually involve instructions to keep a log of thoughts, behaviors, and moods. The log will also include written records of their efforts towards practicing new skills or coping strategies. Clients write down changes that happen 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 people with depression to learn how to break complex tasks into smaller, more manageable components. Doing this increases their likelihood for achieving success with tasks that just feel too big to handle when they are depressed. For example, if cooking an entire meal seems overwhelming to a person with depression, then he might be encouraged to do whatever part of that larger task he can manage. He can feel good about making one course of the meal on a particular day. Teaching people with depression 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. This will result in more rewarding successes which increase mood and fuel 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 with weekly therapy appointments.  However, the therapy can be adjusted by increasing or decreasing the frequency and number of sessions to fit patients' needs.

Cognitive behavioral therapy is a good fit for people who are willing to talk and set goals and that also 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 thinking about their own thinking process. It is also not usually a good fit for people that dislike logical debate and argument used to examine the appropriateness or truth of their thoughts. Finally, it is also not a good fit for those that are interested in a less directive therapist, or who are unwilling to monitor their thinking, behavior, and feelings outside of therapy sessions.

Dialectical Behavioral Therapy (DBT)

Dialectical Behavioral Therapy is a hybrid form of CBT and is also evidence-based therapy.  It was developed by Marsha Linehan, Ph.D. when she noticed that some of her therapy participants were highly reactive to changing their behavior as a component of CBT. She concluded that some sensitive patients find it difficult to benefit from CBT because of the emphasis on changing behavior. Therefore, she added an acceptance component to her treatment approach. She began to encourage therapy participants to both accept themselves, and to change their behavior. DBT is "dialectical" because acceptance and change seem to be conflicting goals. However, it is clear that some therapy participants can only begin to change once they truly accept themselves and their current situation. To promote this acceptance, DBT teaches mindfulness. Mindfulness refers to the non-judgmental observation of moment-to-moment awareness. Mindfulness techniques borrow heavily from Eastern meditative practices.

This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to situations in which they react negatively. They learn which coping skills to apply in a sequence of events, thoughts, feelings, and behaviors to help avoid negative emotions such as those that might trigger major depressive disorder.
Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy was developed by Steven Hayes, Ph.D. and is another hybrid form of cognitive behavioral therapy (CBT). It is quite similar to DBT in that it also teaches clients about mindfulness and Eastern meditative practices. This therapy focuses on "cognitive defusion."  What this means is that during times of distress, we often become "fused" or merged with our thoughts and feelings.  We then make them more important than they really should be. In a sense, we start to believe that we are our thoughts and feelings. We can mistakenly believe our thoughts and feelings represent facts about our world and ourselves.

Traditional CBT encourages people to change their thoughts and feelings. In contrast, ACT encourages people to simply notice and accept their thoughts and feelings for what they are. That they are merely thoughts and feelings of no particular importance other than the importance we actually give them. People learn to say to themselves, "Oh, I'm having a thought about feeling depressed. I'm feeling like it would be good to go to bed for the day." From this perspective, there is no desire to be depressed. It is merely a thought about those things. Therapy participants learn to fully experience the present moment without attachment to specific thoughts and feelings. Eventually people discover their core values and commit to a course of action based on those values. Acceptance and commitment therapy is an evidence-based treatment for addictions as well as several other disorders.