Cognitive approach- treating depression

• Cognitive element:

  CBT begins with an assessment in which the client and the cognitive behaviour therapist work together to clarify the client’s problems. They jointly identify goals for the therapy and put together a plan to achieve them. One of the central tasks is to identify where there might be negative or irrational thoughts that will benefit from challenge.
• Cognitive behaviour therapy is the most commonly used psychological treatment for depression and many other mental health problems.
• Behaviour element:

  CBT then involves working to change negative and irrational thoughts and finally put more effective behaviours into place.
• Beck’s cognitive therapy is the application of Beck’s cognitive theory of depression. The idea behind cognitive therapy is to identify automatic thoughts about the world, the self and the future- this is the negative triad. Once identified these thoughts must be challenged. This is the central component of the therapy.
• Beck’s cognitive therapy:

  As well as challenging these thoughts directly, cognitive therapy aims to help clients test the reality of their negative beliefs. They therefore might be set homework, such as to record when they enjoyed an event. This is sometimes referred to as the ‘client as scientist’, investigating the reality of their negative beliefs in the way a scientist would. In future sessions, if a client says there is no point in going to events, the therapist can produce this evidence and use it to prove the client’s statement are incorrect.
• Ellis’ rational emotive behaviour therapy (REBT) extends the ABC model to an ABCDE model- D stands for dispute and E for effect. The central technique of REBT is to identify and challenge irrational thoughts.
• Ellis’ REBT:

  zFor example, a client may talk about how unlucky they have been or how unfair things seem. An REBT therapist would identify these as examples of utopianism and challenge this as an irrational belief. This would involve a vigorous argument. The intended effect is to change the irrational belief and so break the link between negative life events and depression. This vigorous argument is the hallmark of REBT.
• Ellis identified different methods of disputing. For example, empirical argument involves disputing whether there is actual evidence to support the negative belief. Logical argument involves disputing whether the negative belief logically follows from the facts.
• As individuals become increasingly depressed, they tend to increasingly avoid difficult situations and become isolated, which maintains or worsens symptoms. The goal of behavioural activation is to work with depressed individuals to gradually decrease their avoidance and isolation and increase their engagement in activities that have been show on to improve mood. The therapist aims to reinforce such activity.
• A strength of CBT is evidence that supports its effectiveness for treating depression. March et al. compared CBT to antidepressant drugs and also to a combination of both treatments when treating depressed adolescents. After 36 weeks, 81% of the CBT group, 81% of the antidepressant group and 86% of the CBT plus antidepressants group were significantly improved. So CBT was just as effective when used on its own and even more so when used alongside antidepressant. CBT is also a fairly brief treatment so it’s also cost-effective. This means CBT is widely seen as the first choice of treatment.
• A limitation of CBT for depression is the lack of effectiveness for severe cases and for clients with learning disabilities. In some cases, depression can be so severe that clients cannot motivate themselves to engage with the cognitive work of CBT. They may not even be able to pay attention to what is happening in a session. The hard cognitive work involved also means it is unsuitable for clients with learning disabilities. This suggests CBT may only be appropriate for a specific range of people with depression.
• Although, there is now some recent evidence that challenges the idea that CBT not suitable for people with severe depression and learning difficulties. A review by Lewis and Lewis concluded that CBT was as effective as antidepressant drugs and behavioural therapies for severe depression. Another review by Taylor et al. concluded that, when used appropriately, CBT is effective for people with learning disabilities. This means that CBT may be suitable for a wider range of people than was once thought.
• Another limitation is CBT’s high relapse rates. Although CBT is quite effective in tackling the symptoms of depression, there are some concerns over how long the benefits last. Relatively few early studies of CBT looked at long-term effectiveness. Some more recent studies suggest that long-term outcomes are not as good as had been assumed. Ali et al. assessed depression in 439 clients every month for 12 months following a course of CBT. 42% of the clients relapsed within six months, 53% relapsed within a year. This means CBT may need to be repeated periodically.