Depression and Cognitive Behaviour Therapy

Introduction.
Dave I can feel it, I can feel it Dave, I have feelings too Dave Ok HAL said Dave.
This extract is not, A CBT counsellor called Dave disregarding his clients feelings
and emotions, but an extract from the movie 2001 A Space Odyssey. (Kubrick 1968).
However it is a useful illustration of one of the more common views, that CBT
counsellors are not concerned with their clients feelings and emotions. But I hope to
show that in fact CBT counsellors are indeed concerned with their clients internal
mandala of feeling, Emotions, behaviour, and thoughts, and as counsellors the
specifics, as to how these are related in a particular way, to different mood disorders
such as depression.
Background of C.B.T.
Cognitive Therapy was developed By Aron T Beck in the 1960s as a result of his
research on depression. (Corey 2005 p.283.) The theory is based on the idea that
instead of reacting to the reality of a situation, a person can sometimes react in an
ineffective and self defeating manner, to his own distorted viewpoint or cognitions
that are triggered by inappropriate or irrational thinking patterns. (Paula Ford Martin
2001). Beck initially a practising Psychoanalyst found that results of his research on
depression were in conflict with the psychoanalytical view that depression is anger
turned inwards. He states (1976 p.336) that the cognitive model gives a much
simpler explanation of the patients problems than did psychoanalytical theory.

Behaviour therapy particularly the work of B.F. skinner has had an ongoing influence
on C.B.T. in particular the empirical approach and the use of how principles of
learning derived from the experimental laboratory can be applied clinically (Corey
2005 p.229.) In relation to behaviour therapy Beck states (1976) that through his own
clinical observations and systematic studies, while behaviour therapy was effective
because of the cognitive changes it produced, it was prone to error without the
understanding of the patients ideas, feelings, and wishes that are available through
the cognitive approach the principle that there is a conscious thought between an
external event and a particular emotional response is not generally accepted by the
major schools of Psychotherapy (Beck 1976 p.27). Moreover C.B.T. as a therapeutic
approach is constantly evolving,( Mari Keenleyside 2007) from the initial work by
Beck, to include areas such as the work of Segal on Mindfulness based CBT, and to
what is now considered 3rd Generation C.B.T .which includes Constructive
Psychotherapy which Michael J. Mahoney (2005 p.1) defines as a metatheoretical
perspective that embraces diverse traditions in medicine, philosophy, psychology, and
spiritual wisdom So C.B.T. is on a continuous path of development, it is a
phenomenological approach that by collaboration with the client uses an empirical
method, to verify what is going on for the client now, testing it, and acknowledging
the clients personal paradigm (Eoin Stephens 2007). Indeed far from not dealing with
clients emotions it has become a very Holistic and collaborative form of therapy.
Depression and C.B.T.
The mood disorder depression is forecast by the World Health Organisation to become
the leading cause of disability world wide by 2020 .While there is still debate as to
what depression is, W.H.O. defines it as a common mental disorder that presents
with depressed mood, loss of interest in pleasure, feelings of guilt or low self worth,

disturbed sleep or appetite, low energy, and concentration.

(www.W.H.O.who.int/mental_health/management/depression/definition p 1.)
The same source also provides the following facts on depression;

Depression occurs in persons of all genders, ages, and backgrounds

Depression is common affecting about 121 million people world wide.

Depression is among the leading causes of disability worldwide

Depression can be reliably diagnosed and treated in primary care

Fewer than 25% of those affected have access to effective treatments

Despite the ongoing debate around depression most people would agree that it
consists of a combination of biological, genetic and psychological factors
(www.depression guide 2008)
W.H.O. on treatments and their effectiveness does nail its colours to the mast stating
Antidepressant medications and various forms of psychotherapy are effective for 6080% of clients, www.who.int/mentalhealth/management/depression
But a recent report entitled Mental health awareness and attitudes in Ireland carried
out by the National Office on Suicide Prevention, found that fifty per cent of those
surveyed, would not want it known if they had a mental illness. The report states it is
clear that significant levels of stigma still exist (www.vhi news/n30407c.jps 2008).
A key premise of Cognitive Therapy is that thoughts or cognition which can also
include images have a major effect on our emotions and moods such as depression.
Beck called these type of thoughts Automatic thoughts and he became aware these
thoughts appeared to happen for the client as if by reflex and that the contents of these
thoughts tended to be peculiar not only to the individual patient but to other patients
with the same diagnosis Beck (1976p37). Consequently a client with depression had
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similar thoughts, to other clients presenting with the same mood disorder. He noted
that these thoughts, tended to involve a degree of distortion or self deception of
reality. A more ancient school of psychology, Buddhism shares this and many other
aspects with C.B.T. referring to a fundamental teaching of Buddhism on Dependant
Origination and personal internal formulations David Brazier (2000) says

The castles in the air constructed by our mind called internal formulations are at
best glosses on reality. They become truths of that particular person, but these truths
are not necessarily true. They involve some degree of self deception.

What is the relevance of all of this to a client presenting with depression? Beck
contends regarding depression, that what is at the basis for the depressed person is
that the client feels he is lacking some element or attribute that he considers
essential for his happiness (1991p.104) Beck explored the sense of loss experienced
by a depressed client and found that their psychological disorder resolves around a
cognitive problem. For the depressed person there are distortions specific to his
presenting issue such as a negative view of his world, a negative concept of himself,
a negative appraisal of his future: the cognitive triad. (1991 p.105). When the
depressed client experiences a loss, his mental cognitive constructs, tend to be over
generalised and exaggerated such as ,I am nothing without her, I will never be happy
again ( Beck 1991 p.110) The clients view of reality is distorted by his dysfunctional
thoughts and core beliefs. So at the core of CBT is the connection between thoughts,
mood, behaviour, and physical reaction and the clients environment as can be seen in
the diagram below. ( Mari Keenleyside 2007)

Thoughts & Images

Physical Reactions

Emotions/ Moods

Behaviour / Activity

As stated by Greenberger and Padesky 1995 p4)

the five areas are interconnected .The connecting lines show that each
different aspect of a persons life influences all the other areas So far from
not dealing with emotions this model demonstrates how changes in our
thinking affect our behaviour, mood, physical reactions and can lead to
changes in our social environment. Understanding how these interactions
take place help us to understand our problems.

Jacqueline B Pearson (p.99-118) Categories the clients dysfunctional thinking which

as shown above is connected to the other aspects of the clients paradigm;

Derivatives of the clients underlying irrational beliefs, which are automatic

thoughts which also tend to be irrational, for example a young man whos
irrational belief was until I correct all my defects, I will not be accepted or
loved reported to his therapist the following automatic thought, I dont
belong on this nature hike; when the others find out how little I know about
nature, theyll ignore me

Maladaptive thoughts, seem accurate, logical, and realistic; however

focusing on them causes negative moods, impairs behavioural functioning,
impedes productive thinking about the situation, and reinforces underlying
irrational beliefs For example a student who repeats to herself I am not
prepared for the exam, maybe not be strictly speaking unrealistically, but this
pattern of thinking impedes rather than promotes effective exam preparation.

Distorted thoughts, these involve an unrealistic view of reality or involve

illogical reasoning

So for a depressed client as a result of selective abstraction, Beck states (1989 p.119)
the patient over interprets daily events in terms of loss and is oblivious to more
positive interpretations; he is hypersensitive to stimuli suggestive of loss and is blind
to stimuli representing gain.
An example of a case formulation of a client presenting with depression is shown
below .It is a hypothesis of what is going on for the client, worked out in collaboration
between client and counsellor:
. ( Stephens Eoin 2007) (Amalgamation of charts mine)
Case Formulation in C.B.T. / Case Formulation of Depression in C.B.T.

(Early) Experience
Parental Neglect

Schema / Core beliefs (unconditional)

I am a worthless Person

Assumptions/expectations
Rules intermediate beliefs(conditional)
To be a worthwhile person I must be loved by everyone

Compensation Strategies
Try too hard to please

Negative Automatic Thoughts

Ill never be loved by anyone

Current Trigger
People avoid him

Emotions
Low Mood

Behaviour
Low activity

Biochemical Reactions
Tired, Little appetite

C.B.Tof Depression in Clinical Practise

The UK National Institute for Clinical Excellence (NICE) has issued a guide on The
Management of Depression in Primary and Secondary Care (2004 p.6) They state
that the clients psychological social and physical characteristics, and their

interpersonal relationships should be taken into account when deciding the

appropriate intervention, together with the type of depression with which the client is
presenting. When it comes to medication they recommend the use of SSRIs as they
are purported to have less adverse side effects. In Relation to Psychotherapy they say
that CBT is the psychological treatment of choice ( Nice Clinical guidance 23 p.11)
In General the guidance does not recommend the use of antidepressants in cases of
mild depression, antidepressants and CBT is recommended in moderate to severe
depression, and for patients who have not made an adequate response to other
treatments for depression (for example antidepressants and brief psychological
interventions) consider giving a course of CBT of 16 to 20 sessions over a period of
6-9 months ( Nice Clinical guidance 23 p.11) For Clients with recurring depression
they recommend a relatively new development mindfulness based CBT.
Consequently C.B.T. in practise involves:

Definition of problems

Exploration / Assessment

Formulation

Intervention /Techniques

Evaluation

In Practise I have found it very helpful at the initial session to facilitate the client in
drawing up a list of issues they would like to work with, Pearsons
(1989p19)maintains that the clients Problem list focuses the treatment and is a first
step in the above approach .For the exploration and assessment various resources
such as the Beck Depression Inventory or Mental Health Handbook (Trevor Powell
2007) which contains examples of :

Hospital and Anxiety and Depression Scale.

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worrying thought questionnaires,

physical symptoms inventory and fear inventory,

Similar to Beck and Byrnes depression inventories these not only provides a score
for the client in relation to these issues, but also provides details of the clients moods/
emotions, thoughts, physiology, and behaviour, which can then be then used to
populate these aspects for the initial case formulation, which is carried out in
collaboration with the client. Any assessment of a client with depression should
include a review of suicide risk. The ASIST model includes the following risk
assessment:

Is the client having thoughts of suicide

Does he have a current suicide plan

Does he have pain that he feels is unbearable

Does he feel he has any resources

Has he prior suicide behaviour

Is he now or in the past receiving mental health care

Regarding formulation, as well as providing a hypothesis of what is going on for the

client, it also highlights the possible best area, and method for initial intervention. An
example of a client Mary presenting with Depression, anxiety, and panic attacks,
the priority was to intervene with behavioural approaches such as

deep muscle relaxation,

breath work

Distraction techniques

Not only because the panic attacks were having a severe effect on the clients ability
to continue at work, but that the initial intervention at the behavioural level can be

more effective when the client is not ready for other interventions such as cognitive
restructuring The use of bibliotherapy and the education of the client in being able to
make the connection between thoughts, moods, physiology and behaviour coupled
with exploration of environmental issues , such as creating ,a time line of the losses
she had experienced in the last three years, all help in making some shift in the
clients low mood . Interventions such as cognitive restructuring, by use of a
Negative Unhelpful Thought record allows the client to capture her moods and
automatic thoughts, and to rate the intensity of her moods. Challenging the validity
by looking for evidence that supports, or does not support these automatic thoughts
can help the client see that at best these thoughts are a hypothesis. Finally looking
for more balanced or alternative thoughts can lead to a shift in emotional response
to a situation .related to the believability of the alternative or balanced thoughts
(Greenberger and Padesky p109.1995) Assumptions and Core beliefs are what roots
automatic thoughts below the surface, and regarding these Jacqueline B Pearson says
that to teach the patient the nature of his own beliefs, she proposes the use of David
Burns downward arrow technique, starting with the automatic thoughts to find the
conditional and absolutist, drivers of the dysfunctional thinking. On Going
evaluation is a key aspect of CBT which both charts the clients progress and the
efficacy of the approach. Further developments in C.B.T. continue such as the recent
introduction of Mindfulness based CBT. By Segal, Williams, and Teasdale. This is
found to be effective particularly in preventing relapse in depressed clients. Based on
the Buddhist practise of mindfulness meditation, its aim is to teach the client to
move from a doing mode of existence to a mode of simply being. This has the effect
of changing the clients relationship to moods and emotions. The client becomes less
involved in his own drama and becomes more of a spectator. (Segal et al 2002).

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Through mindful awareness, the client observes his moods, like an old man watching
children at play. Furthermore Oxford university department of psychiatry has a
project to look at the role of imagery in the process of depression where the client
has a negative interpretation bias and also negative intrusive mental imagery
They hope to develop a CBT training, that will allow the client to have a more
positive interpretation of these image, and to develop a means of reducing negative
intrusive mental images, and of promoting positive mental images.(www.
Psychiatry.ox.ac.uk 2008)
Conclusion
While W.H.O. maintains a high level of success in the treatment of depression, there
are obviously other factors that explain, that while interventions such as C.B.T. and
medication are effective 60-80% of the time, yet only 25% of those affected seek
treatment. Stigma is obviously one of these factors, but another particularly in Ireland
must surely be access to a sufficient number of trained C.B.T. counsellors. However
both of these issues are in our own hands as a society to address, and with continuing
developments of Becks original work, clients with the mood disorder depression,
should see some light at the end of the tunnel

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