CBT for Depression

Dr. Rijusmita Sarma

Aaron Temkin Beck, MD has magnanimously contributed to the field of psychotherapy in the form of Cognitive Behaviour Therapy. After training as a psychoanalyst, his earliest research focused to validate psychoanalytic constructs of hostility turned inward toward the self in depression. However, he found that dreams of patients with depression contained fewer themes of hostility instead had greater themes of defectiveness, deprivation and loss and he recognized that when they were awake these themes were present even in their thinking. Unlike the psychoanalytic theory that focused on the innate need to suffer in patients with depression, Beck’s theory focused on underlying negative beliefs associated with loss or failure. Beck examined the spontaneous negative thoughts (automatic thoughts) and cognitive distortions expressed by his patients. He found that his patient’s thoughts about a situation had more influence on their emotions and reactions than the situation itself. He helped them identify and change the way they thought about situations and engage in more adaptive behaviours, which helped them recover and feel better. He also helped them work on underlying maladaptive beliefs about themselves, others, the world and the future. And such work by the legend put in motion the development of Cognitive Therapy (now known as Cognitive Behaviour Therapy).

Depression is a mood disorder characterized by persistent low mood and loss of interest in activities the person earlier enjoyed for a period of more than two weeks. Paul Blenkiron has developed a mnemonic for the symptoms of depression:

D: Depressed mood

E: Energy lost (fatigue)

P: Pleasure (Interest lost)

R: Retardation or agitation

E: Eating change (appetite/weight)

S: Sleep change

S: Suicidal thoughts

I: Impaired concentration

O: Only me to blame (self-blame/worthlessness/guilt)

N: Not able to function

Aaron Beck helped understand the psychopathology of Depression through his concepts of ‘Cognitive triad’ and ‘Cognitive model of Depression’. Beck’s cognitive triad is also known as the negative triad explains the three key elements in a person’s negative spontaneous thoughts when experiencing depression. The triad explains that the automatic negative thoughts are about: the self (eg. I am worthless), others or the world (eg. Nobody loves me) and the future (eg. My future is dark). The cognitive model of Depression proposed by Beck explains that depressive symptoms are generated and maintained by a combination of maladaptive cognitions. It throws light on how life experiences can lead to the development of maladaptive schemas (organizing framework of the mind) which may remain dormant otherwise but may be triggered or activated by critical life events. These activated maladaptive schemas contribute to the development of the spontaneous negative thoughts (Automatic negative thoughts) which in turn leads to the manifestation of the affective, cognitive, behavioural, somatic and motivational symptoms of depression. The symptoms of depression may again fuel the automatic negative thoughts. Therefore it can be comprehended how dysfunctional thoughts play a significant role in generating and maintaining depressive symptoms.

Aaron Beck was influenced by the stoic philosopher Epictetus and the basic philosophy of CBT is ‘Men are disturbed not by events but by the views which they make of them’. The interpretation, evaluation and meaning attached to an event hugely determine the emotions and reactions to the same. The cognitive model proposes that dysfunctional thinking is present in all psychological disturbances and when people learn to identify and evaluate thinking in an adaptive and realistic way they experience improvement in their emotions and behaviour. Cognitions are the proximal and most important determinant of emotions. CBT however is in alignment with the bio-psycho-social perspective of etiopathogenesis of an illness as it does not claim that dysfunctional thoughts alone lead to emotional distress; rather it forms an integral part of the distress.

CBT explains the three levels of cognition as: a) Automatic thoughts (they are the spontaneous thoughts, images, memories, interpretations, assumptions about an event, situation or experience. They are the most superficial level of cognition), b) Intermediate beliefs (rules, attitudes and assumptions) and c) Core beliefs (they are the most central ideas about ‘self’. They are the most fundamental level of belief, they are global, rigid and overgeneralized. The most important core beliefs are: helpless core beliefs, unlovable core beliefs and worthless core beliefs. People’s basic beliefs may also be about the world and other people). The cognitive conceptualisation of a patient helps understand these levels of cognition and also the genesis and maintenance of the current state of distress. The errors or dysfunctions in the thoughts are known as cognitive distortions, and they present the reality in a distorted way contributing to psychological distress. Therefore CBT aims at helping people identify their distressing thoughts and evaluate how consistent they are with reality. Once the distortions are identified they are assisted in forming more rational and reality-aligned alternative thoughts which help in experiencing improvement in terms of emotions and behaviour. Thus according to the cognitive model, by working on the dysfunctional thoughts and perceptions noticeable changes in emotions and behaviour can be manifested. For more enduring and consistent improvement in emotions and behaviour, working on the core beliefs may help achieve the desired goal. In addition to the cognitive interventions, CBT also focuses on behavioural activation, activity scheduling, graded task assignment, behavioural experiments and assignments etc.

CBT is considered to be one of the most evidence-based form of psychotherapy for managing depression. CBT has been extensively tested and a sufficient number of studies and researches have been conducted, the results of which advocate the efficacy of CBT in depression. A meta-analysis of 115 studies has shown that CBT is an effective treatment strategy for depression and combined treatment with pharmacotherapy is significantly more effective than pharmacotherapy alone. Evidence also suggests that relapse rate of patients treated with CBT is lower in comparison to patients treated with pharmacotherapy alone. In addition to depression, CBT is effective in a wide range of mental health conditions like anxiety disorders, eating disorders, obsessive compulsive disorder (OCD), post traumatic stress disorder (PTSD) and even psychosis.

A patient X, 19 yrs, F presented with symptoms of persistent low mood, global loss of interest, fatigue, increased irritability, restlessness and mild decrease in appetite since a period of one month. As per the patient and the informant (mother) she started developing these symptoms after her medical entrance results were declared which she couldn’t clear. According to the informant, she was almost fine before the results got declared but she has always found it difficult to handle failures even as a child and got nervous before exams. BDI was administered, where she scored 24 which indicated moderate depression. She was evaluated for self-harm and suicidal thoughts which were not present as reported. The diagnosis was shared with the patient and informant (after taking the patient’s consent) and the different forms of treatment including psychotherapy and pharmacotherapy were explained and they chose to move forward with CBT. As therapy progressed she revealed her main areas of concern as:

a) “I feel guilty and worthless as a child as I have disappointed my parents.”

b) “I don’t think I will be able to do anything good in life.”

c) “I am a failure as I couldn’t clear the entrance which was so important for me and my parents.”

Thought record sample was used to have an elaborate understanding of her thoughts, emotions and behaviour. Cognitive conceptualisation revealed that she had a very critical father who used to compare her with her cousins and rebuke and humiliate her every time she did not perform up to his set standards. She had conditional assumptions where she associated her worth (as a person and as a child) with her performances and that it was terrible to fail. Her compensatory mechanisms were that she developed very high standards for herself and used to over-prepare and work very hard (even for small assignments) and she used to be very critical of herself. Her core beliefs were found to be “I am incompetent” revealing helpless core belief and “I am worthless’’ revealing worthless core beliefs. Therapy was commenced with behavioural activation using activity scheduling. Cognitive restructuring at different levels of cognition was done as therapy progressed and through homework assignments patient was educated to identify and evaluate dysfunctional thoughts and replace them with healthy functional alternatives. Improvement in emotions and behaviour of the patient was noticed by the therapist and also reported by the patient and informant.

Pual Blenkiron in his book ‘Stories and analogies in Cognitive Behaviour Therapy’ has explained Depression using metaphors having themes of darkness, battle and being trapped and burdened. The powerful pangs of this dark demon can be painful and debilitating but liberation is possible even if it may not be linear or absolute. Aaron T Beck said, “Some authors have conceptualised depression as a ‘depletion syndrome’ because of the prominence of fatigability; they postulate that the patient exhausts his available energy during the period prior to the onset of depression and that the depressed state represents a kind of hibernation during which the patient gradually builds up a new story of energy.