Explaining/Treating

• Negative triad - Beck proposed three kinds of negative thinking that contributes to depression: negative views of the world, the future and the self. Such negative views lead a person to interpret their experiences in a negative way and make them more vulnerable to depression.
• ABC model - Ellis proposed depression occurs when an Activating event triggers an irrational Belief, which in turn produces a Consequence, e.g., an emotional response such as depression. The key to this process is irrational beliefs.
• • Aaron Beck (1967) suggested a cognitive approach to explaining why some people are more vulnerable to depression than others.
  • In particular it is a person’s cognitions that create this vulnerability i.e. the way they think
  • Beck suggested three parts to this cognitive vulnerability
• FAULTY INFORMATION PROCESSING (Beck 1967)

  • People who suffer from depression will focus on the evidence that proves their negative thoughts and ideas about themselves, the world or the future, and ignore the evidence to the contrary that is often right in front of them
  • This faulty processing can also include crippling perfectionism
• NEGATIVE SELF SCHEMAS (Beck 1967)

  • Weissman and Beck supported this idea through a 1978 study. Thought processes were measured using the dysfunctional attitude scale. Participants were asked to fill in a questionnaire by ticking whether they agreed or disagreed with certain statements. When given therapy to improve their negative self schemas, the symptoms of depression were reduced with less negative self ratings
• A self schema refers to the metaphorical package of information an individual has, or believes they have, on themselves.
• THE NEGATIVE TRIAD (Beck 1967)

  • A negative view of the world - things like: “The world is an evil, miserable place with no good” can create the impression that there is no hope anywhere.
  • A negative view of the future - things like: “In ten years time, I will have died”, reduces hope and enhances depression
  • A negative view of the self - things like: “I’m a failure” can confirm already existing self beliefs and reduce self esteem even more.
• Ellis' ABC Model

  • Activating Event: external stimuli trigger irrational thoughts, for example, failing a test.
  • Beliefs: Ellis referred to crippling perfectionism as 'musturbation'. I-can't-stand-it-itis is in reference to the belief that everything is a major disaster
  • Consequences: maladaptive behaviour, depression triggered
• The view that depression is linked to irrational thinking is supported by a lot of research. Hamnen and Kratz (1976) - depressed participants had more lapses in logical judgement than non depressed patients. Bates et al (1999) found that depressed participants who were given negative self-autonomic-thought statements became more and more depressed, showing more symptoms than previously.
• What if negative thinking is a result of depression, not a cause?
• The cognitive approach blames the client and leaves all responsibility to them. Stating that the disorder is just embedded in the client’s mind leaves all chances of treating this, to them. While this could be a good thing, to isolate the issue and put it into perspective for the client, it could mean that environmental causes are neglected.
• The cognitive approach has practical applications in treating depression. CBT (Cognitive Behavioural Therapy) has been cited as the best form of treatment for depression, especially when paired with drugs (Cuijpers et al 2013 found that this combination was very effective).
• Alloy and Abrahmson (1979) suggested that depressive realists actually see the world accurately, and their ‘irrational thoughts’ are not actually irrational, but down to earth. They stated that non-depressives see the world through rose tinted glasses and find positives in situations where there aren’t any.
• The biological approach to understanding mental disorders suggests that genes and neurotransmitters  may cause depression. Zhang et al 2005 found that a gene related to low levels of the neurotransmitters serotonin were 10 times more likely to develop depression.
• The success of drug therapies for treating depression suggest that neurotransmitters do play an important role; the medication alters the levels of specific neurotransmitters and reduces the symptoms
• At the very least, a diathesis stress approach might be advisable, suggesting that individuals with a genetic vulnerability for depression are more prone to the effects of living in a negative environment, which then leads to negative irrational thinking.
• Beck's theory has good supporting evidence - much research has supported the proposal that depression is associated with faulty information processing, negative self schemas and the triad of impairments. A 2019 study (Joseph Cohen) tracked 473 adolescents, regularly investigating their cognitive vulnerability. They found that this was a significant predictor in depression.
• Beck's theory does not explain all aspects of depression - the theory explains the basic symptoms of depression, however, it is a complex disorder with a range of symptoms, not all of which can be explained
• Ellis' theory only offers a partial explanation - some depression does occur as a result of an activating event (reactive depression). However, not all depression arises as a result of an obvious cause (this is endogenous depression, that Ellis doesn’t really explain)
• Ellis' theory does not explain all aspects of depression - this explanation also does not explain why some individuals experience anger associated with their depression or why some patients suffer hallucinations and delusions.
• COGNITIVE BEHAVIOURAL THERAPY (CBT)

  • CBT is the most commonly used psychological treatment for depression, as well as other mental health problems
  • The therapist aims to make the client aware of the relationship between thought, emotion and actions
  • CBT can help people to change how they think (cognitive) and what they do (behaviour). These changes can help them to feel better.
• How does CBT work?

  • Psychotherapy
  • The therapy also includes behavioural techniques such as behavioural activation (encouraging patients to engage in those activities they are avoiding)
  • It focuses on the ‘here and now’ problems and difficulties. Instead of focusing on the causes of the distress or symptoms of the past, it looks for ways to improve the state of mind now.
  • When the parts of the sequence are clearly outlined and understood, they can be changed
• The CBT process

  • Meet with a therapist for between 5 and 20, weekly, or fortnightly, sessions. Each session will last between 30 and 60 minutes
  • Some CBT therapists work with the techniques influenced by Beck and some work with the techniques influenced by Ellis.
  • ASSESSMENT ---> Formulation / Goals ----> Treatment ←Homework ←Monitoring
• Beck's Cognitive Therapy:

  • Beck developed a therapy to challenge the negative triad (beliefs) of the client
  • First, the client will be assessed to discover the severity of their condition
  • The therapist will establish a baseline (or starting point), prior to treatment, to help monitor improvement.
• For Beck's cognitive therapy, the relationship between thought and emotion is integral.

  • To feel better, you must think positively.
  • The client is asked to provide information about how they perceive themselves, the future and the world
  • The therapist would use a process of reality testing
  • The therapist might ask the client to do something to demonstrate their ability to succeed
• Beck's cognitive therapy directly challenges the irrational thoughts.
• Ellis' REBT (Rational Emotive Behavioural Therapy)

  • Extends ABC model to ABCDE
  • Dispute
  • Effect
• REBT

  • REBT is based on the premise that whenever we become upset, it is not the events taking place in our lives that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged etc.
  • REBT challenges the client to prove these statements, and then replace them with more reasonable realistic statements (empirical disputing / logical disputing)
• COMMON IRRATIONAL THOUGHTS

  • Ellis identified what he saw as the most common faulty beliefs experienced by people with mental health problems
  • I am worthless unless I am competent at everything I try
  • I must be approved of and loved by everyone I meet
  • My unhappiness is always caused by external events; I cannot control my emotional response
  • It is upsetting when things are not the way I would like them to be
• REBT is moreso about identifying, isolating and treating the irrational belief or view of the event, whereas Beck’s CBT is more focused on understanding a distorted interpretation of the world, the self and the future, and minimising the impacts this has through positive reinforcement.
• One of the major differences is how Ellis’ model initially doesn’t evaluate the thought, and runs with it being a truthful reflection of an event. Beck, on the other hand, evaluates it from the offset, putting it to a reality test.
• REBT has a more directive, active process, and hopes to change dogmatic views for significant ‘philosophical change’. This is the main drawback, as some patients would prefer more protocol driven treatment. CBT is more cautious and protocol driven - hoping for relief of symptoms or a return to more normal functioning. Unfortunately, this means there are less opportunities for tools given to the patient to continue their ‘treatment’ through everyday life.
• Newark 1973:

  • One group with anxiety, the other without. Asked if they agreed with some of Ellis' statements.
  • RESULT: A total of 65% of the anxious participants agreed with statement a) compared to 2% of non anxious participants. For statement b), 80% of anxious participants agreed, compared to 25% of non anxious participants
  • CONCLUSION: People with emotional problems think in irrational ways
• CBT IS EFFECTIVE

  • It is the most effective psychological treatment for moderate depression
  • It is as effective as antidepressants for many types of depression (Fava et al, 1994)
• CBT MAY NOT WORK FOR THE MOST SEVERE CASES

  • In some cases, depression may be so severe that patients cannot motivate themselves to engage in therapy
  • In these cases, it is possible to treat the patient with antidepressants and then CBT can commence at a later date
• KELLER ET AL 2000

  • Recovery rates (from depression)
  • 55% drugs alone
  • 52% CBT alone
  • 85% when used together
• SUCCESS MAY BE DUE TO THE THERAPIST-PATIENT RELATIONSHIP

  • Research has shown that there is little difference between CBT and other forms of psychotherapy
  • It may be the quality of the therapist-patient relationship that makes the difference to the success of the treatment rather than the treatment itself
  • Simply having the opportunity to talk to someone who will listen could be what matters most
• SOME PATIENTS MAY WANT TO EXPLORE THEIR PAST

  • CBT focuses on the here and now, however there may be links to childhood experiences and current depression and patients might want to talk about these experiences.
  • They can find this present-focus very frustrating
• AN OVEREMPHASIS ON COGNITION

  • There is a risk that in focusing on what is happening in the mind of the individual may end up minimising the importance of the circumstances the individual is living in
  • There is thus an ethical issue for cognitive behavioural therapists here, and it is important for therapists to keep in mind that not all problems are in the mind.