COGNITIVE THERAPY FOR DEPRESSION
Cognitive therapy is an active approach which is limited over time, structured, flexible, humanistic, orientated at promoting insight and is used to treat a variety of psychiatric disorders, such as depression, anxiety, phobias and obsessions. The aim of cognitive therapy is to sort out problems, which are identified by the patient by means of an agreement made between the patient and the therapist, in which the client defines the limits and the therapist checks that the method is being used correctly. Cognitive therapy is based on the idea that affection and the patient’s behaviour are largely determined by the way in which these aspects structure his/her vision of the world and him/herself. This knowledge is based on behaviour and basic assumptions developed through previous experiences which are organised hierarchically and which are relatively stable and functional. It follows that, what is nowadays intended as a cognitive activity, is something much broader than a conscious and rational thought as is often believed. A cognitive activity is an automatic and pervasive activity which is profound and which generates meaning.
The summary of a clinical case, about a patient called Maria, is a good example to show what happens during a course of cognitive therapy.
The psychical suffering described in the Maria’s case corresponds to the model of emotions formulated by the cognitive theory, which has an important adaptive value. Failures and disappointments are a part of everyone’s life but they do not have to necessarily determine the onset of symptoms or disorders, however they are often the reason why self-complexity develops. In psychopathological phenomena, suffering maintains itself over time and is rooted in a context of coherent behaviour, which appears to organise itself in such a way as to perpetuate the suffering. It is as if the system stays in a state of continual transition without producing a new equilibrium. In the ‘neurotic paradox’, a change to a person’s symptomatic vision of him/herself is accompanied by intense emotions (anxiety, desperation, anger and so on).
What is depression from a cognitive therapy point of view?
A person who develops a depressive disorder often shows signs a basic characteristic disorder, through which he/she constructs an image of Self and a personal way to relate to others and expectations of others which lead onto to a life style which is founded on feelings of personal inadequacy and solitude. The individual perceives him/herself as incapable of being loved or having attention paid to his/her most intimate and personal needs, thus he/she is forced to find attention and acceptance through socially accepted actions, even at the cost of doing things that he/she finds difficult and taking on roles that are different to his/her own desires and preferences, thus he/she is destined to come across indifference and hostility if he/she shows his/her true nature. Sometimes, especially regarding events of great emotion, perceived as confirmation of one's unhappy destiny, deep personal crises occur, which may end up having clinical relevance.
It should be noted that, although depressive disorders are common, mood disorders are recognised and should be distinguished from depressive syndrome.
Depressive disorder This is a particular way of being that stably orders a person’s experiences, significant attributions and personal knowledge in such a way that these things are experienced in a harmonious way by the person. It goes without saying, therefore, that one experiences this as the only possible and correct way to explain what happens in life. This leads to a particular personal balance and way to adapt to one's social life that, once achieved, is not necessarily associated with feelings of intense suffering.
Depressive syndrome This indicates the surfacing, which is usually episodic, of intense emotions related to experiences of guilt, shame or anger, permeated by a pervasive sense of sadness and desperation. These negative feelings strongly interfere with a person’s vision of the world, his/her past and future and his/her cognitive, operative and social skills. This depressive crisis infringes on the person’s equilibrium therefore, and causes a change that can result either in the equilibrium becoming more functional (useful crises), or in a collapse of his/her vision of the world and sense of existence.
Depressive disorders should not only be perceived as they are described by clinical classifications, which are more popular and are characterised by a constant depressive mood, loss of interest, psychomotor retardation and social isolation, rather they should be understood as always attributing negativity to life events, based on a peculiar vision of Self and the world, formed from everything from one's most significant experiences to childhood experiences regarding who the individual was close to.
During cognitive therapy, the depressed patient is guided to gradually recognise what Beck calls the cognitive triad of depression: negative thoughts about oneself, the world, and the future. The therapy course is carried out as follows:
The therapeutic techniques are aimed at identifying, verifying and correcting the patient’s distorted ideas and dysfunctional beliefs. The patient learns to dominate problems and situations that he/she previously thought impossible to overcome, re-evaluating and correcting his/her thoughts. The cognitive therapist helps the patient to think and act more realistically and adaptively, thus reducing the patient’s psychological problems and symptoms. This approach consists of teaching the patient to:
Cognitive therapy generally consists of weekly sessions, 15-25 times. Seriously or moderately depressed patients require two sessions a week for 4-5 weeks, or one session a week for 10-15 weeks. Diversely from psychoanalytical therapy, the content of cognitive therapy is focused around the 'here and now' problems. Very little attention is given to childhood experiences if they do not help to clarify the present situations, and interpretations of subconscious factors are not carried out. The cognitive therapist actively collaborates with the patient when he/she explores psychological experiences, decides on activities and is assigned homework. Cognitive therapy differs from behavioural therapy as it puts more emphasis on the patients internal experiences, like his/her thoughts, desires and everyday dreams and habits. The general strategy of cognitive therapy can also be differentiated from other types of therapy for the emphasis it puts on empirical research of patients' automatic thoughts, interferences, conclusions and basic assumptions. Cognitive therapy formulates hypotheses regarding dysfunctional ideas and beliefs the patient has about him/herself, experiences and his/her future, and it tries to verify the validity of the hypotheses in a systematic way. It also focuses on promoting insight into recognising cognitive distortions in relation to certain moods and situations, along with awareness of cognitive processes which support the maintenance of cognitive distortions, that is, identifying basic cognitive patterns. This insight is aimed at providing the skills needed to adequately master and face interpersonal situations and intrapsychical factors which play an important role in establishing suffering and mental discomfort.
The therapeutic relationship
As in all cases of therapy, the therapist-patient relationship is important because
it provides the means for the progression of the healing process. The therapist
is like a guide, letting the patient acquire the comprehension that will allow
him/her to be more able to confront his/her problems (guided discovery), as well
as acting as a catalyst, with respect to doing things outside of the therapy course
which will help to improve the patient's adaptive skills. A cognitive therapist,
like in other approaches, shows a genuine warmth towards patients and does not
judge them, their experiences or their thoughts about themselves. In contrast
to Rogerian and psychoanalytical therapy, the cognitive therapist plays an active
role in helping the patient to pin point his/her problems, focus on important
areas and propose and re-examine specific, cognitive and behavioural techniques.
Many of the therapist's verbal expressions are in the form of questions, reflecting the basic, empirical orientation and turning the patient's closed thought system into an open system. The therapist actively engages the patient in deciding what to do in each session and in providing feedback regarding the therapist's suggestions and behaviour during the session. Whilst the therapist does indeed attempt to maintain a level of 'warmth' during the course of therapy, patients may still react badly and resist this. Such reactions are usually the most precious parts of the therapy since transference reactions are useful for highlighting the patient's interpersonal distortions. Similarly, resistance is dealt with in terms of implied, dysfunctional beliefs. Since the standard duration of cognitive therapy is about 15 visits over a period of 12 weeks, there is considerable pressure on the both the patient and therapist to make full use of the precious time they have. Therefore, a substantial effort is made to get the patient to do homework, such as writing essays about recognising and responding to negative conditions, mastering cognitive and behavioural practices learnt during the sessions and verifying the proposed hypotheses. The next objective is to promote cognitive restructuring. This involves making changes to the patient's systematic tendencies when interpreting his/her life experiences and realising future plans. In summary, cognitive therapy is a learning experience in which the therapist plays an active role in helping the patient to discover and change his/her cognitive distortions and dysfunctional assumptions.
Cognitive therapy suggestions for depressed people
This type of therapy is particularly good for patients who are more interested in understanding and thus controlling their cognitive distortions and the consequences of them, rather than exploring the subconscious and distant origins of them. The patients must also be people who want to and are able to, right from the beginning and with the help of the therapist, take on an active role in changing their habits and passive behaviour and who perceive the sense of domination and mastery as a new sense of security, which is related to the proposed change. Another important element to verify is that the subject lives in a positive way and not as an aggressor, the former being learnt directly from the therapist, and that, in following stages, the patient is able to identify with the therapist’s behaviour so as to be able to take on this positive behaviour themselves.
Cognitive therapy can be considered as the only treatment when a patient presents the clinical conditions listed below:
When to use cognitive therapy for depressed individuals
Cognitive therapy can be part of a combination of treatments, such as pharmacotherapy, sleep deprivation, and so on, in patients with the following symptoms:
When to use combined treatment
Some people, who ask for cognitive treatment, may have some conditions which do not work well with this treatment, make it ineffective or require special attention, thus the standard treatment course must be changed accordingly.
When not to recommend cognitive therapy
Results and outcome
Cognitive therapy was initially used and tested during treatment courses for unipolar depressed patients at the outpatient clinic of the University of Pennsylvania. The first systematic study about the treatment of depression showed that cognitive therapy produced the greatest percentage of improvements during the twelve weeks of treatment carried out on 80% of patients, a percentage which is higher than the control group treated with imipramine. These results refer to a year of follow-up. Three other studies, carried out at the University of Edinburgh, British Columbia and Pittsburgh, showed that the results of cognitive behaviour therapy were superior to those achieved with antidepressants. Other studies have shown that the results of cognitive therapy were equivalent to those of antidepressant drugs (University of Minnesota, University of Washington) and that the combination of both was higher than each of the two prescribed individually. Other controlled clinical trials, concerning the treatment of depression, have also confirmed the effectiveness of cognitive therapy compared to standard treatments (John Hopkins University and Oxford). It has been shown that certain types of depression are somewhat unaffected by cognitive therapy (such as psychotic and melancholic depression), however, a recent report showed that the aforementioned types of depression respond well treated with both antidepressants and cognitive therapy together.