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March 2017
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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.

Maria’s case

Maria, a 45 year old woman being treated for a dysthymic disorder, talks about the event which she claims was the onset of her symptoms: 

‘It was a nice morning in the late Spring and I was taking a walk in the mountains with my husband and some friends. I went ahead of the group slightly because I wanted to walk faster and really enjoy this day of leisure. I had not enjoyed some time on my own for quite some time because of the long illness my mother had suffered from, which eventually took her life, and the stress that two teenagers cause, who have now got better, so to speak, however I had been awake the whole night before the trip to the mountains because one of them had come home late. Time had flown by so I thought I would give myself a bit of time alone. Were it not for that constant worry about the children and, now, for that weight that I felt in my chest and the cold sweat that was beginning to appear on my forehead, I would have been happy. I slowed down and the others over took me, including my husband who was talking to a friend. Each step got heavier and an intense feeling of discomfort started to take over me. I did not understand, I had always been a good walker, even as a girl, which was when I lost my father to a heart attack. Now, though, I felt very bad, I could feel my blood pulsating in my temples and I had the impression I was staggering. I thought about calling for help but my mouth was so dry that no sound came out. My mind filled with bad premonitions and I thought about how the others would not even notice. When my husband reached me I was in a sorry state and could not say anything other than ‘help me, I’m dying’. However, the worst was over, yet from that moment on my life had changed: I slowly became more careless, I shunned friendships and even my passion for the house and my children vanished.’

In the following session, after having done the homework she was assigned to identify the thoughts that went through her mind during that situation, Maria was able to pin down what the exact thought was that went through her mind during the crisis: ‘my heart is exploding, I’m going to die like my father.’ A later study then pointed out that she was also thinking that ‘if I die, I will leave my children in a mess and they will hate me for that.’ This discovery shocked Maria a lot as she still felt a lot for her father and she said that she ‘would never have hated him,’ she was always a good daughter and, being the eldest child, she helped in the house in return for respect and affection. Following this, she was also able to recognise that, over the years, she had developed basic assumptions which helped her to always be very helpful to others and she said that 'recognition that I had done my duty was enough to make me feel good.' During the course of the therapy, Maria was able to recognise the benefits inherent to the peculiar construction of oneself and one’s vision of the world, as well as recognise the constraints which inhibit a person. Slowly but surely she also managed to learn how to use the best strategies to deal with new challenges that life puts in front of her.

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).

Let us look at an example. Let us take a person whose vision of Self is that of ‘love’, which is closely and rigidly related to the fact that he/she sees him/herself as ‘efficient, active and happy’. Let us suppose that this person loses a loved one and so he/he feels very sad and depressed. This latter feeling invalidates his/her vision of Self as efficient, active and happy and, if these factors were closely related to the loved one who has recently passed away, this invalidation will make the person feel ‘unloved’. At this point, the person thinks that all the people around him/her will stop loving him/her and this fuels the depression and so the vicious circle continues. Another example is when a person, who interprets his/her experiences in terms of skills and adequacy, truly believes and thinks that ‘if I do not do everything perfectly, I’m a failure’. In this case, the person judges everything in terms of adequacy, even when the situation has nothing to do with being, or not being, competent.

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.

Treatment

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:

  1. Evaluation phase and stipulation of contract 
  2. Exploration of the origin of the problem: how it started and how to deal with it 
  3. Teaching appropriate strategies to neutralise maladaptive automatisms and prescribing experiments so as to validate or invalidate the hypotheses.

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:

  1. recognise his/her own automatic, negative thoughts
  2. recognise the connections between the above thoughts, affection and behaviour
  3. recognise cognitive distortions(*)
  4. examine the evidence for and against automatic, distorted thought
  5. replace negative ideas with more realistic ones
  6. learn how to identify and change dysfunctional beliefs, which tend to distort experiences.
(*) Cognitive distortions in psychopathology:
  1. Arbitrary interference (deduction): this refers to the process of coming to a conclusion without any evidence that supports the conclusion, or when the evidence available opposes the conclusion which has been drawn. For example, a person sees an old friend cross the street to say 'hi' yet he/she still thinks 'he/she did not want to see me.'
  2. Selective abstraction: this consists of focusing on details which are out of context and ignoring more obvious aspects of the situation, as well as conceptualising the experience on the basis of this out-of-context element. For example, a student may notice that one or two peers look bored during a presentation he/she is doing so this student comes to the conclusion that everyone was bored.
  3. Excessive generalisation: this refers to drawing general conclusions in all situations, based on one single incident. For example, a person may disagree with his/her parents thus he/she thinks 'I cannot have long-term relationships with anyone.'
  4. Exaggeration and minimisation: this concerns assessing the relative importance of special events, for example, a student is given a questionnaire and he/she underlines the enormous difficulties experienced whilst doing it: 'it is impossible to answer these questions', thus he/she believes 'I know nothing about this subject'. 
  5. Personalisation: this describes the tendency to associate events to oneself, even though there is no reason to do so.
  6. Dichotomous thinking: the patient tends to interpret things as black or white, or both colours. For example, a young university student may think of himself as very clever, successful and popular. Then, when he starts to slip, he has mental ups and downs, until he thinks of himself as unable, a failure and unpopular. 

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.
terapiaMany 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

  1. When two types of antidepressants have been tried and have both failed to improve the situation;
  2. When there has only been partial response to adequate doses of antidepressants;
  3. When therapy with other psychotherapists has failed or only produced a partial response;
  4. Following the diagnosis of minor mood disorders (for example, dysthymia, cyclothymia);
  5. When the patient's mood is sometimes responsive to environmental events;
  6. When the patient's mood is sometimes related to negative cognitions;
  7. When there are symptoms of somatic problems (fatigue, appetite change, weight, libido);
  8. Following a reality test concerning how long the patient can concentrate for and if he/she is able to memorise things;
  9. When the patient is unable to tolerate the effects of medicine (this is a sign of a high risk related to pharmacotherapy).

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

  1. When there has been a negative or only partial response to cognitive therapy;
  2. When there has been a partial, and not complete, response to pharmacotherapy;
  3. When there has been hardly any adaptability to medicine;
  4. When there are signs of persistent, maladaptive functions with depressive syndrome on an intermittent basis;
  5. When there are signs of serious somatic symptoms and noticeable cognitive distortions ('no hope');
  6. Reduced memory and concentration: obvious psychomotor problems;
  7. When the patient is severely depressed and suicidal;
  8. When immediate family members have responded to antidepressants in the past;
  9. When there is a history of mania in the family and patient.

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

  1. When the patient suffers from schizophrenia, an organ illness, alcoholism or mental retardation;
  2. When the patient suffers from an illness which causes depression;
  3. When the patient's memory is impaired and the result of the aforementioned reality test is poor (delirious, hallucinations);
  4. When the patient has a history of manic episodes (bipolar depression);
  5. When there is a family history of response to antidepressants;
  6. When there is a history of family members with bipolar disorder;
  7. When there is an absence of life or event triggers;
  8. When there is a lack of evidence of cognitive distortions.

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.

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