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How Cognitive Behaviour Therapy can be used to help someone with Depression. 

Patrick Kelly MIACP, BA (Hons) Counselling & Psychotherapy
Oranmore Counselling Centre
Castlecourt
Oranmore
Galway

This essay provides a definition of depression along with the diagnostic characteristics. There is a discussion on the clinical recommendations for Cognitive Behaviour Therapy (CBT) and the efficacy of it. The CBT view of depression is then discussed. This is followed by an insight into the structure of CBT sessions. Finally the essay will look at the major strategies employed by CBT in relation to depression.  

In order to treat a client it is necessary to assess them. To do this it would help if one was familiar with the DSM-IV (American Psychiatric Association 2000). Depression is listed on Axis 1 which contains the mood disorders. The DSM-IV simply defines mood disorders as disorders that have a disturbance in mood as their predominant feature. They are divided into three groups: Depressive Disorders; Bipolar Disorders and Mood Disorders based on etiology. Qualification for each group, and consequent diagnosis, depends on the presence or absence of certain episodes: Major Depressive Episode; Manic Episode; Mixed Episode and Hypomanic Episode. The DSM-IV provides clear definitions and criteria for each of these episodes and subsequent definitions and criteria for the related Mood Disorder diagnoses. CBT was mainly designed to treat non-bipolar and non-psychotic depression i.e. no presence of manic episodes, hypomanic episodes, hallucinations or delusions (Hawthorn, K., Salkovskis, P. M., Kirk, J. & Clark, D. 1989). 

The list and characterisations of the Depressive Disorders, as provided by the DSM-IV, are: Major Depression: One or more Major Depressive Episodes (at least 2 weeks of depressed mood or loss of interest accompanied by at least 4 symptoms of depression). Dysthymic Disorder: At least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet the criteria for a Major Depressive Episode. Depressive Disorder Not Otherwise Specified: Disorders with depressive features that do not meet criteria for other Disorders or depressive symptoms that have inadequate or contrary information.

The National Institute for Clinical Excellence (2004) provide recommendations for dealing with depression. Patients diagnosed with mild depression or a patient who does not want an intervention should be directed to self-help programs based on CBT. For mild and moderate depression, a referral to a psychological therapy focused on depression such as (CBT or Problem Solving Therapy) should be considered for 6-8 sessions. For severe depression, a combination of anti-depressants and CBT should be considered. CBT should be used for recurring depression (NCCM 2004).

In order to judge the efficacy of CBT, NCCM identified 30 acceptable trials to form their opinion. Their conclusions were as follows. It can be established that CBT is as effective as anti-depressant treatment in reducing depressive symptoms across the spectrum of depression severity. Tolerability is higher with CBT than with anti-depressants (Bates, A. cited in Boyne, E. 2003). Adding a course of CBT to anti-depressant treatment (ADT) is more effective than treating with anti-depressants alone (NCCM 2004).  In Ireland the method of counselling preferred by the HSE is CBT (HSE 2006). Anthony Bates (Boyne, E. 2003) also provides studies that say that relapse rates are lower from CBT than from ADT. 

Bates (cited in Boyne 2004) traces the roots of CBT theory back to ancient Greece. Epictetus considered that we are upset not by what happens to us but the way we look at things. This idea lends itself to the theories by the two major founders of CBT: Albert Ellis and Aaron Beck. Ellis saw people as having irrational thoughts and beliefs about themselves and their interactions with the world. Beck saw people in terms of living from the perspective of their core beliefs. These beliefs allow them to make assumptions about the world. Sometimes these assumptions become rigid and may not be a true reflection of reality and therefore lead to dysfunctional behaviour. The work of CBT is to tackle these irrational beliefs and assumptions and there is a large focus on dispelling negative automatic thoughts (NATs). Fig.1. demonstrates the CBT view of depression (Stephens, E. 2008). 

Eoin-Stephens-CBT
Unlike other forms of treatment CBT is highly structured and aims to be time limited. Before a client is considered for therapy one has to ascertain if they are suitable for the service offered. This takes into account a formal diagnosis, the severity of the depression and how suitable and capable the person is to sustain a therapeutic relationship.

The structure of treatment is as follows: CBT starts with the initial interview. As with all forms of therapy it is essential to establish a rapport and use active listening skills to ensure that the client feels understood and listened to.  
 In the initial interview there is an assessment process. This gathers relevant information in regard to the cognitive model (fig.1). From this one can form a hypothesis and share this with the client. One is also on the look out for suicidal intent. A useful tool in assessing a client for depression is the Beck Depression Inventory (BDI) (Stephens 2008). This not only can act as an initial assessment tool but can also help to monitor progress as interventions have been made. One can gauge from it whether or not the therapy is successful. The lower the score on the BDI the less severe the depression is and vice-versa. 
 The next step is to define and focus on goals. A question like “how would you like this situation to be different?” would help in this area. This keeps a focus on the therapy and provides a benchmark. 
 One must next explain the way this form of therapy works, from a practical and a theoretical point of view. One deals with expectations from both parties such as duration of therapy and homework assignments. It is important to explain how negative thinking is a vicious cycle that needs to be broken and also it is important to emphasise that change is possible. 
 A target is agreed upon for immediate intervention. Appropriate homework, monitoring tools and reading are provided. 
 It is also important to get feedback from the client, and this should be ongoing throughout the therapy. 

Subsequent sessions should take a structured form also:
 Firstly an agenda is agreed upon for the session. This focuses the session.
 Clients need to know that they are expected to become more aware and reflective throughout the process. This can be facilitated by a discussion on their progress since the last session. The emphasis in CBT is on self-help; therefore a discussion on homework from the previous session is necessary. Results, awareness and difficulties encountered are discussed.
 The majority of the session is taken up with the day’s major topic/s. This is likely to have come up in the agenda but may come up in the course of the session. It is better to focus on one or two issues and deal with them thoroughly than to deal superficially with a few topics.
 Then one must plan homework that is appropriate arising from the session. One must also deal with and discuss possible barriers to completing the assigned tasks such as NATs. This increases the likelihood of the assignments being completed. 
 The final stage is feedback on how the session went (Hawthorn et. al. 1989).

We have looked at the structure of the sessions for dealing with depression. Now it is necessary to examine the major strategies employed in CBT. These strategies are sequential but may overlap and in some cases some are not necessary. It all depends on the characteristics of the individual client. 
The first strategy is a cognitive approach (Hawthorn et. al. 1989). This provides the building blocks for a client to learn how to avoid dwelling on negative thoughts which can lead to distress. The client learns how to distract themselves. There are various techniques which the client learns. Theses are: focusing on an object; developing sensory awareness of their surroundings; performing various mental exercises; focusing on pleasant memories or fantasies and engaging in absorbing activities which occupy the body and mind. Another technique is counting thoughts allowing the client to number their NATs and put them aside. 

The behavioural strategies are designed to facilitate the client to monitor and schedule mood elevating activities. Clients with depression tend to engage in thought processes that avoid or devalue engaging in such pleasurable activities.  Monitoring activities helps the client to test how what they are thinking about doing activities with the reality of actually doing them. This is done by recording activities and associated moods and thoughts on an hourly basis. Scheduling encourages the client to plan activities on an hour by hour basis, based on their records. The technique of graded task assignment is then used to break down tasks to a manageable level and overcome any difficulties (Hawthorn et. al. 1989). 

The cognitive behavioural strategy teaches the client to recognise, question and test their NATs. The client learns the cognitions that lead to such thoughts such as: overgeneralization; selective abstraction; dichotomous reasoning or jumping to conclusions without sufficient evidence. These thoughts are recorded and then challenged and explored for alternatives. The client is then encouraged to run behavioural experiments to test the validity of their negative assumptions (Hawthorn et. al. 1989). 

The next stage is to create preventative strategies to cope with and avoid the onset of depression in the future (Hawthorn et. al. 1989). In order to achieve this one needs to delve deeper than the surface negative automatic thoughts. The client needs to learn to identify and challenge the dysfunctional assumptions which underlie them. Clients are prepared for set-backs in the future and they can use their set-backs while in therapy to learn to deal with future set-backs positively. When the therapy is at an end the client is encouraged to explore likely events in the future which could instigate depression. This deepens awareness and prepares them to deal with such events. 

CBT is a much more structured and directive approach than other forms of Psychotherapy. It is also generally more accepted by the scientific and medical community than the other forms. It is a very important tool for dealing with depression. However it does purport to deal with cognition and behaviour in order to affect emotions, which runs counter to most other psychotherapies. There is a large emphasis on the positive whereas other therapies allow for the negative feelings and consider them just as healthy as the positive ones. There seems to be no room to work on the origin of depression and there is no major provision for holding the client and letting them own their own feelings. 


References:

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders-IV-TR. Arlington VA: American Psychiatric Association.

Boyne, E. (2003). Psychotherapy in Ireland. Dublin: The Columba Press.

Hawthorn, K., Salkovskis, P. M., Kirk, J. & Clark, D. (1989). Cognitive behaviour therapy for psychiatric problems. Oxford: Oxford University Press.

Health Services Executive (2006). Guidance document for the provision of counselling in  a primary care setting. Dublin: Health Services Executive.

National Collaborating Centre for Mental Health(2004). Management of depression inPrimary and secondary care. National clinical practice guideline number 23. U.K.:  National Institute for Clinical Excellence. Retrieved 20/03/08 from http://www.nice.org.uk/nicemedia/pdf/cg023fullguideline.pdf

Stephens, E. (2008). Cognitive behavioural therapy for depression. Cognitive Behavioural Therapy Ireland. Retrieved 21/03/08 from http://www.cognitive.ie/_mgxroot/page_10766.html
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