Depression and Cognitive Behavioural Therapy
How cognitive behavioural therapy can help ease depression
Depression is a mood disorder that affects how you feel and how you think. It can be debilitating leading to detachment from life. The Depression Cycle by Kennerley shows the typical cycle of depression:
Depression cycle kennerley
Depression often includes a loss of pleasure in things someone used to enjoy, a lack of joy in doing anything and negativity about oneself and the world. It really is a dark place and the worst thing someone can say to a depressed person is “Snap out of it”. Depression is a physical illness that manifests in the brain and needs intervention (anti depressants and/or talking therapy such as CBT).
Depression and behavioural activation
A CBT therapist helps a depressed client make the link between their low mood and their lack of activity. The less we do, the more depressed we tend to feel. we want to hide in bed and often don’t want to wash or dress. Together a client and their CBT therapist put together an activity schedule to help the client works towards doing more things, even if at first that means getting up at 2pm instead of 4pm. ‘Baby steps’ are key. Activities that promote a sense of pleasure and mastery (feeling competent and able to do things) is a practical and effective way to slowly pull away from the hold depression can have.
Depression and thoughts
A CBT therapist helps a client understand how their thinking should not be trusted when they are depressed. Three areas are especially affected: thinking about oneself, others and the future. Depressed thinking can be very dysfunctional. Typical dysfunctional thinking in depression: only noticing the negatives, being highly self critical, overgeneralising (one person treats you badly, therefore everyone must be bad), and generally feeling hopeless about everything. Thoughts aren’t fact but when we are depressed, we lose the ability to rationalise our thinking in the same way as when we are mentally healthy. CBT therapists often focus on behaviour before focusing on thoughts to help shift the depression.
CBT therapists do their best to understand the framework that the client uses to interpret the world around them. It is also important to undersyand what factors are triggering and maintaining the depression. There are many different causes for this. Some clients end up depressed after suffering from stress for too long without doing anything to deal with their stress. There is also a genetic component to depression, making some people more predisposed to getting depression. Depression is often caused by a combination of things – genetic and environmental.
Understanding how a client interprets the world can help to minimise self fulfilling prophecies and unhelpful conclusions that a depressed client may come to. CBT helps to challenge innacurate thinking and look for rational alternatives.
CBT therapists use a technique known as “guided discovery” to uncover further details from the client.
Guided discovery can help a client discover useful information that can be used to help them to gain a better level of understanding (and to help the client adopt this strategy for themselves as the basis for exploring their own beliefs). An ability to use guided discovery to create doubt in place of certainty, providing the client with the opportunity for re-evaluation and for new learning to occur.
Guided discovery also helps the client develop hypotheses regarding their current situation and to generate potential solutions for themselves. The client develops a range of perspectives regarding their experience (by examining evidence, considering alternatives, weighing advantages and disadvantages) through open communication and discovery rather than through debate. CBT therapists avoid attempting to impose a particular point of view on the client (for example by reliance on debate, persuasion, “lecturing”, or “cross-examining” the client) and to ensure that this basic ‘stance’ pervades all interactions with the client.
Identifying inaccurate assumptions
Depression distorts our thinking and a CBT therapist is adept at helping a client to identify these assumptions that are unhelpful and exacerbate the depression. A good CBT therapist will be open to exploring with the client and will not impose their own opinions nor lecture a client.
Behavioural experiments are created collaboratively between CBT therapist and client and are designed to help the client test out their beliefs. For example, they may have a belief that there is no point in getting out of bed because life is awful and they won’t feel any better and if they can’t stay in bed they will feel worse. A simple experiment would be to create an experiment whereby the client gets out of bed and walks to the shop. They rate their mood before and after and rate how they think they will feel. More often than not the client finds out that their mood is elevated despite their belief that they won;t feel any better. In this way a shift can take place where the client begins to see that their thinking isnt always accurate. Behavioural experiments are a large component of CBT and VERY effective.
CBT therapists teach their clients how to design their own behavioural experiments, ulitmately helping them to become their own therapist.
Understanding unhelpful coping mechanisms
When we are depressed, we often engage in behaviours that make our depression worse. We withdraw from the world, hide from others and detach. Secondary coping behaviours (such as avoidance, inactivity or rumination) play a significant role in the maintenance of depression and while thoughts are important, the therapeutic focus is on the context in which these arise (the antecedents and consequences) rather than their content.
One key element to treating depression: clients should be helped to learn how to engage in activities despite feelings such as fear, sadness or low motivation).
I know when I have been depressed in the past, going out would seem the hardest thing to do. I would rather do anything than have to go out and see others yet when I forced myself, 100% of the time, I felt better afterwards.
TRAP: Trigger Response Avoidance Pattern
Keeping a list of the above can be very useful when trying to do more (wash more often, get up earlier, go out etc) to shift depression, It can help a client to identify behaviours that are holding them back. This is useful when avoidance is prominent.
ACTION: Assess; Choices; Try new; Integrate; Observe; New behaviours
Clients can use the ACTION tool (which Assesses the function of behaviour(s), to consider their Choices for action or avoidance Try new behaviours, Integrate these behaviours into a routine, Observe the outcome and persist in trying out the New behaviours. Write down what is possible, try them out and rate how good they made a depressed client feel.
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CBT therapists can also help clients create short and long term goals. A sense of purpose can be a wonderful antidote to depression but the stage of depression of the client needs to be assessed. A severely depressed client will not be ready to create or consider goals initially.
Clients are also taught how to distract themselves and when it is safe to do this for their own safety. One of the most problematics issues with depression is that clients tend to overthink and analyse and this further compounds their depression. CBT therapists can teach clients effective strategies to counteract rumination.
CBT therapists identify where clients may have a limited repertoire for solving specific problems that confront them, distinguishing between a skills-deficit and avoidance. They assist in helping clients develop proactive rather than passive coping strategies (i.e. reacting to difficulties rather than engaging with them) and help clients define and specify short- and long-term goals, as part of an action plan. The client learns to ensure that problem solving behaviours are reinforced by ‘natural’ (internal) environmental reinforcers, in order to ensure that they are maintained.
A client’s social network is always considered when treating depression, The more friends and family a client has, the better. The amount of engagement from the client is also key and social contact is encouraged when appropriate, depending in the stage of CBT treatment.
Depression can be well managed and even cured. Cognitive behavioural therapy is an evidence based technique that works. Not everyone will respond well to cognitive behavioural therapy but it is definitely an intervention worth considering if you, or someone close to you suffers from depression.
I used to suffer from chronic depression and CBT has helped me to create my own behavioural experiments and understand the importance of DOING things to break the cycle. I also learned not to take my thinking seriously and accept that my thoughts were inaccurate when depressed. Get the help you need now. It made all the difference to me.
Photo by JenXer