Cognitive-behavioral therapists focus on changing thoughts and behaviors that contribute to mental disorders, such as depression. In this type of therapy, the therapist does not work to help the patient uncover “insights” in order to change, nor is change dependent on the therapist-patient relationship, as in other forms of psychotherapy.
Rather, a patient learns how to adapt or change their thoughts and behaviors in order to distinguish impaired thoughts from healthy, functional thinking that correlates directly with healthier behaviors. To change thoughts and behaviors, the therapist teaches the patient skills that the patient practices outside of the clinical setting, eventually integrating these skills automatically into every part of his or her life.
Treating depression with CBT employs the same key principles as using CBT for other mental health disorders, but customizes the approach as it applies to depression, and to the individual’s specific problems.
And although change is not dependent on the therapist-patient relationship, the therapeutic alliance between the two is critical. This means that both the therapist and the patient work together, collaboratively, to identify problems, set goals, assign and plan homework assignments, and challenge negative thoughts, emotions, and behaviors. In CBT, the therapist is said to be an “active” rather than a passive listener.
Problem Solving and Goal Setting
After the therapist and patient establish a therapeutic relationship, which involves the therapist educating the patient on CBT and its central concepts, and the patient explaining the reasons for seeking treatment, therapy begins.
For depression, the patient and therapist prioritize problems and state the goals that will ameliorate the problems, talking through them and writing them down. This serves as the groundwork for all therapy sessions, being constantly reviewed and reworked if necessary.
Establishing this list places the problems in context, and employs a positive approach that demonstrates the manageability of problems. This takes the patient’s focus off of depressive symptoms and feelings. For instance, instead of focusing only on the sadness and pain one feels with depression, the problem-goal list emphasizes that solutions exist, that actively pursuing solutions ultimately lessens the sadness or other negative emotions associated with this disorder.
The following is a list of problems and goals for a hypothetical patient dealing with depression:
|Social isolation or withdrawal from activities||Identify a social activity(ies) to join or get involved with|
|Lack of self-esteem or self-worth||Increased sense of worth and self-acceptance|
|Working excessive amounts of overtime||Decrease work hours to 40-hour weeks|
|Conflict with significant other/partner||Improve relationship with partner|
The Progression of Therapy
CBT attempts to be focused and solution-based, and tries to keep the total amount of sessions short, usually from 14 to 16 sessions. For this reason, therapeutic progress is measured from the first session.
Depressed individuals often walk into the first session feeling overwhelmed and hopeless. Many start to feel their burdens lift simply by stating them and writing them down. For many, they need a therapist to help articulate their problems since a constant stream of negative thoughts about many areas of their life consume and confuse them.
During the first phase of therapy, the therapist begins to identify the thoughts and behaviors contributing to the problems. Using the hypothetical patient above, the therapist first tackles one of the most common and disabling problems of depression – social withdrawal. Depression causes individuals to disengage from activities and social pastimes. Yet these pastimes with others, the activities that provide distractions from problems, and the inherent sense of fun and enjoyment they offer, are what keep individuals from developing or feeding depressive thoughts.
In other words, therapists identify avoidance behaviors. Questioning the patient about why he or she refuses to go out and socialize, the therapist hears that the patient feels too tired, wouldn’t actually enjoy the activity anyways, or feels that he or she is not likable or fun to be around.
The therapist helps the patient see that it’s first easier to change a behavior – such as going out or joining a social group or event – than a feeling. Feelings are much harder to willfully control than behaviors.
Also feeding the problem of social isolation, the second problem of low self-esteem is evident in the patient’s claim that no one likes him or her anyways. This is also a common dysfunctional thought that many who are depressed express.
The therapist challenges this negative thought through Socratic questioning, asking for specific examples, questioning assumptions, detailing misconceptions and showing the patient that this is only a “theory” and not a “fact.”
Working on self-esteem skills, the therapist might begin working on interpersonal communication skills, assertiveness training, posture, and actions with others, such as making eye contact, and active listening skills.
In between sessions, the therapist has the patient practice all the skills taught in the session, and also encourages taking action before giving into feelings that are loaded with self-doubt and distress. Soon the patient observes a difference in feelings and ways of thinking about activities simply by doing them.
The therapist might also have the patient list or keep a journal of activities attempted and the results. For instance, if a goal is to reduce the number of overtime hours worked, and to work on assertiveness skills, the patient is instructed to use constructive “I” statements with a boss or coworker to explain why he or she has to reduce work hours. Such an example might be: “I don’t mind working overtime during peak times of business, such as during tax time, but I can’t continue to work the same amount of hours the entire year. My overall productivity is suffering because of the amount of work I am expected to do.”
The patient is coached by the therapist on how to use these “I” statements, as well as how to speak, refrain from becoming emotional, and even how to stand when facing his or her manager. Role-playing is an important aspect of CBT.
The All-or-Nothing Syndrome
Therapists who work with depressed patients see cognitive distortions as factors that affect almost all the problems that patients report, and one of the most common is the “all-or-nothing” attitude or way of thinking. Also called black and white thinking, this underlying belief distorts reality. By addressing this type of thinking, therapists are able to help patients address each problem and work toward each stated goal.
An example of all-or-nothing thinking from the hypothetical patient above is present in each problem. The patient believes that he or she will be rejected by every person in every social situation encountered, that when any activity is attempted, such as doing artwork, exercising, or trying to find a new job, that he or she will be unsuccessful so that means he or she is a failure. Or if a partner in a relationship gets mad or upset, that means the partner is going to leave the patient.
For each of these statements, the therapist challenges the patient on their veracity, getting the patient through Socratic questioning, to realistically prove their validity. Sometimes just bringing an awareness to the patient of this type of thinking helps the patient identify the negativity and maladaptive assumptions on which he or she bases these thoughts.
Therapists might use some form of a dysfunctional thought record with the patient, having the patient write down a negative or maladaptive thought each time it is experienced, identifying the situation, emotion, and automatic thoughts that take place. Then during a therapy session, alternative, healthier thoughts and responses are identified and added to the patient’s log. This gives the patient repeated practice at confronting negative thoughts, and replacing them with more healthy, constructive thoughts. It’s a powerful self-empowerment tool that shows patients that they control their thoughts, their minds, their lives – that no one person or situation can take over and destroy their lives.
There are many other distorted beliefs linked to depression, such as negatively predicting the future. The patient predicts that he or she can’t keep a partner, that regardless of what happens the partner will always leave, or that getting a new job is impossible.
Other distorted beliefs focus on “shoulds,” such as “I should work overtime,” or “I should give in to whatever my partner asks of me;” or focusing only on negative aspects of him or herself, such as weight, thinning hair, or poor eyesight.
The therapist must act as a detective, identifying all negative or distorted thoughts, and, through coaching, guiding, homework, and role-playing, challenge and restructuring these thoughts. As the therapist and the patient work through each problem, they examine how maladaptive thoughts and maladaptive behaviors become a vicious, endless cycle, and how to break the cycle.
The Patient as Therapist
The goal of therapists working with the CBT model is to get the patient to become his or her own therapist, to be able to quickly identify maladaptive thoughts and behaviors during difficult situations, and to implement their own action plans. CBT trains patients to view each negative thought as a possibility or hypothesis, not an actual fact. By challenging and changing beliefs, the patient implements a form of cognitive restructuring, a main tenet of CBT.
An important aspect of CBT is to set realistic goals. Setting a goal of never getting down or sad again is not a realistic goal. Chances are, a patient with depression must manage depression his or her entire life. So the purpose of CBT is to give the patient the skills and tools needed to manage symptoms when they reappear.
According to the “Oxford Textbook of Psychotherapy,” edited by Glen O. Gabbard, Judith S. Beck, and Jeremy Holmes,” relapse prevention consists of four components:
- Identifying high-risk situations
- Learning coping skills
- Practicing coping skills
- Creating a lifestyle balance
During therapy, the therapist helps the patient determine which situations are likely to cause a relapse. For the hypothetical patient above, that patient might identify a fight with a partner, or constant demands by a manager to work overtime as possible triggers for relapse.
In addition, lifestyle balance is especially crucial for managing depression, and includes the proper amount of sleep and sleeping patterns, exercise, participation in social activities, relaxation techniques, eating healthy, and refraining from excessive consumption of alcohol.
From time to time, a recheck with the therapist is a good idea. However, the overall goal of CBT is to get individuals to see how they have the power and ability within themselves to tackle and control this mental health disorder.