Cognitive therapy’s early success arose largely from the impact of Beck et al.’s (1979) book on depression, coupled with research trials showing the effectiveness of this new approach. In this chapter, we will describe some of the classic CBT strategies for depression. See also Chapter 17 for a brief description of some of the more recent innovations in working with depression, including mindfulness-based cognitive therapy and behavioural activation.
Characteristics of depression
As well as depressed mood, depressive disorders are marked by many other symptoms. In the American Psychiatric Association’s Diagnostic and Statistical Manual (APA, 2000) these other symptoms include: loss of interest or enjoyment in activities; changes in weight and appetite; changes to sleep patterns; being either agitated or slowed up; loss of energy; feeling worthless or guilty; poor concentration; and suicidal thoughts.
The classic Beck model of depression centres on the ‘depressive cognitive triad’, i.e. a pattern of negative thoughts about:
Perception, interpretation and recall of events may all be negatively biased, so that depressed people are more likely to notice information that is consistent with their negative view, more likely to interpretany information negatively and more likely to remember negative events. Negative events are typically attributed to stable, global and internal factors and seen as having lasting consequences and implications for self-worth (Abramson et al., 2002) – e.g. ‘This is my fault’, ‘I always mess up like this’, ‘It just shows how useless I am’. Positive events, on the other hand, are attributed to temporary, specific and external factors, with no lasting consequences – ‘That was just a lucky break’, ‘It’s the exception that proves the rule’, ‘It only worked out because my wife helped me’.
The primary symptoms of depression are often exacerbated by secondary negative or self-defeating thoughts about the symptoms of depression, thus giving rise to vicious circles. For example:
Common maintenance processes
Figure 12.1 shows some of the common maintenance cycles in depressed people (as always, these are possibilities to explore, not rules to force your clients to obey!). First, there is a possible vicious circle linking depressed mood with negative biases and negative interpretations of symptoms, which leads to a negative view of the self, thus maintaining the depressed mood. Second, those negative biases and symptoms of depression may lead to reductions of activity (‘I’m too tired, there’s no point …’), which maintains the low mood because activities that previously gave pleasure or a sense of achievement are lost. Finally, the depressive biases and symptoms may lead to reduced attempts to cope and deal with problems, which leads to increased hopelessness and thus reinforces the depression.
Figure 12.1 Common maintenance processes in depression
It follows from the above account that the goals of CBT for depression will usually include:
As always, your task as therapist is to construct a formulation that makes sense for you and your client and then to devise cognitive behavioural strategies that will help to break maintaining cycles. The main approaches to cognitive strategies and behavioural experiments in depression are broadly similar to the standard approaches outlined in Chapters 8 and 9, and, therefore, this chapter, after an outline of the broad approach to therapy, will focus on the interventions aimed at activity and problem-solving, which are particularly characteristic of treatment for depression.
Course of treatment
CBT for depression usually contains the following elements, although, of course, this list needs adapting to your individual client. For instance, severely depressed clients may need more behavioural strategies, especially early in the course of therapy.
Components of CBT for depression
CBT for depression usually contains the following components:
Beck et al. (1979) prescribed a course of therapy lasting 15–20 sessions, with the first few sessions delivered at the rate of twice a week. Many ordinary clinical settings modify this to a standard weekly pattern and, perhaps, also reduce the total number of sessions. Clinical experience suggests that the protocol is sufficiently robust to withstand such modifications, but it is worth considering whether more frequent sessions are both desirable and feasible in particular cases.
Activity scheduling is one of the core therapeutic techniques in CBT for depression (Beck et al., 1979). It is based on the ideas embodied in the ‘Reduction of activity’ vicious circle in Figure 12.1, i.e. the notion that one maintaining factor for low mood is the reduction of activity that commonly accompanies it, which in turn leads to a loss of enjoyment and achievement, thus maintaining the low mood. Activity scheduling was derived from basic behavioural ideas about the need to build up reinforcing activities but has since developed into a sophisticated cognitive strategy. In fact, current conceptions would construe activity scheduling partly as a specialised form of behavioural experiment (see Chapter 9, and Fennell, Bennett-Levy & Westbrook, 2004).
Figure 12.2 The weekly activity schedule (WAS)
The weekly activity schedule (WAS)
The WAS, illustrated in Figure 12.2, is the essential tool for activity scheduling. It is basically a simple timetable grid with hours of the day down one side and days of the week across the top, so that there is a slot for every hour of the day. The version shown here has sufficient hourly slots to accommodate most clients but can be adapted if, for instance, you have a client who has severe early morning waking, so that the grid might need to start at 4 am instead of 6 am. Note also that if you are making a template WAS, it is best to (a) make it much bigger than this, so that there is more space for the client to write (one A4 or letter page is usually sufficient); and (b) leave the days of the week blank so that a client you are seeing, for example, on a Wednesday can start his WAS on that or the following day, filling in the ‘days’ column headings appropriately.
Using the WAS as a record
The first stage of activity scheduling is to use the WAS as a self-monitoring tool, to gather information about the client’s activities. This information may be used in two ways, as in the two approaches to behavioural experiments described in Chapter 9:
In either case, typical guidance for clients using a WAS should contain the following points:
Figure 12.3 shows part of a completed WAS.
Figure 12.3 A sample WAS
Using WAS records
There are three main things for you and your client to look for when the completed WAS is returned.
In addition to these activity-specific observations, the WAS provides an excellent laboratory in which you and the client can begin to observe NATs, noticing how thoughts and behaviour affect each other and using this to encourage the client to start spotting NATs in action (e.g. NATs that block activity). You can watch out for this kind of thought and work with them via discussion or behavioural experiments. For example, if your client’s attempts to do a particular task are blocked by NATs along the lines of ‘I won’t enjoy it’ or ‘I’ll only make a mess of it’, then you could set up a behavioural experiment to see how true that is.
Maria’s WAS immediately showed that her life was currently divided between hectic activity, almost all of which consisted of necessary but unrewarding chores, followed by what she called ‘collapsing in a heap’, when she would just sit and stare into space (often ruminating about how useless she was). This monitoring helped her and her therapist to identify (a) the need to find some activity that she found pleasant or enjoyable; and (b) the fact that despite her constant chores, she placed no value on this activity and still saw herself as ‘useless’.
Using the WAS as a planning tool
The next step is for you and the client to use what you have learned to plan future activity. There are three common ways to improve mood through activity:
During this phase, instead of simply monitoring what he does, the client uses the WAS as a timetable to plan increases in activity and, specifically, activities identified as providing some pleasure or achievement. How much detail is needed, and how much activity should be aimed for, will depend on the individual client: in general, the more depressed the client is, the more detailed planning he may need and the lower the initial goals for activity may need to be. Early on, you may need to be closely involved in planning, but later on the client can take on more of this task for himself.
Figure 12.4 Excerpt from Maria’s activity plan
Maria agreed to construct with her therapist an activity plan (Figure 12.4) that still had time for necessary chores but which also started to build in some time for activities that she used to enjoy, such as watching movies on DVD. An important – although difficult – area for her was re-establishing social contacts. Although she was generally a sociable person who enjoyed contact with others, she had become almost completely socially withdrawn after her years of depression.
Graded task assignment
The best general principle in planning activity is ‘graded tasks’. In other words, aim to build up activity step by step, rather than attempting to go in one jump from no activity at all to being busy all day. Because of the depressed client’s extreme sensitivity to any possibility of failure, it will usually be counterproductive to agree tasks that are too far forward from where the client is now. If he does not manage to complete the task, it will be likely to be counted as a failure and taken as further reason to lose hope. It is usually better to agree a smaller but manageable task. For example, if your client wants to take up reading again after giving up because of concentration difficulties, then it is unlikely that he will be able to read a whole novel by next week. It will usually be better to negotiate a target he believes he can achieve, even if this is only to read one page by next week (but make sure that the target does not get so small that the client sees it as trivial).
Although Maria wanted to get back into social relationships, she was very anxious about how she would manage, and about how others would respond if she tried to make contact. A step-wise programme was therefore agreed, starting with making a brief phone call to her sister, with whom she still had some contact, and working up towards approaching friends with whom she had lost contact and trying to arrange to see them. Only one old contact failed to respond positively to Maria’s approaches, and discussion in session allowed her to keep this in proportion to the many positive reactions she had.
There is some evidence that reasonably high levels of physical exercise may have a significant effect on depression, with some studies finding effects comparable to anti-depressants (Greist & Klein, 1985; Martinsen, Medhus & Sandvik, 1985). Current NICE guidance (2009c) includes a recommendation for structured physical activity as a possible low intensity intervention for people with ‘persistent sub-threshold depressive symptoms or mild to moderate depression’, adding that such activity should:
It is therefore worth encouraging clients to make exercise sessions a part of their activity planning (see also Chapter 10). It has been our experience that some clients initially engage more easily with physical activity than with some of the CBT interventions that require more intellectual application. For example, some adolescents might more readily take to physical exercise and become engaged with CBT that way.
Common problems in activity scheduling
Lack of pleasure
It is important to realise that in the early stages of fighting depression, clients are not likely to enjoy anything as much as they did before the depression. It is important to prepare clients for the fact that initially they will probably have to force themselves to do things even though they do not derive much pleasure from them. Persevering should at least give the client some sense of achievement, and, eventually, the enjoyment should return as well. It is also important to convey the idea of pleasure as a continuum, not all or nothing. We are looking for some increase in enjoyment, not an instant return to full enjoyment.
It is also important that the client recognises that achievements do not have to be at the level of winning the Nobel Prize to be worthwhile. Spending 10 minutes tidying up a messy kitchen drawer can help the client feel he has done something useful today and may be a considerable achievement. It is important to help your client apply realistic standards in evaluating tasks and activities. What was easy when he was well may be difficult (and therefore warrant a higher achievement score) when he is depressed.
When planning activities, it is better to be specific. In other words, try to help the client move from vague goals like ‘I must do more’ to specific activities at specific times, e.g. ‘Go and buy that birthday card on Wednesday morning’. If a goal or target is vague (‘I must do more’) it is all too easy for the depressed person to downgrade achievements or to ‘move the goal posts’: ‘I didn’t really do anything, I bought a few things in town. So what? Anyone can do that.’ If buying the card is set up as a specific task, then there is no doubt that a particular goal has been achieved and it is more difficult to dismiss it.
Jacobson’s dismantling study and the behavioural activation approach
Anyone who might doubt the value of activity scheduling and behavioural methods in treating depression, should read Jacobson et al.’s (1996) fascinating study comparing outcomes between three versions of CBT for depression, based on ‘dismantling’ the classic Beckian therapy. One treatment was normal Beckian therapy, and this was compared with two ‘stripped down’ versions: one in which therapists used only the behavioural components of CBT (including activity scheduling) and one in which they used both behavioural and cognitive methods but only at the level of automatic thoughts, with no direct targeting of assumptions or core beliefs. What they found was that all three treatments produced similar outcomes and also similar changes on measures of negative cognitions. One possible conclusion is that different methods may achieve the same end result of cognitive and emotional change by different pathways. Following on from this study, colleagues of Jacobson’s elaborated their behavioural treatment into a new therapy for depression known as ‘behavioural activation’ (see Chapter 17).
Cognitive strategies in depression
There are two phases of cognitive work in classic CBT for depression. In the first phase the aim is to help the client get some symptom relief by using simple strategies to reduce the impact of NATs on mood (with the useful secondary aim of providing evidence about how thoughts can influence mood). In the second phase, the NATs are confronted more directly, with the aim of helping the client consider them more carefully and, if appropriate, find alternative thoughts through all the methods discussed earlier in this book: finding alternatives, looking for evidence, devising behavioural experiments and so on.
Early cognitive strategies
The goals of these strategies are to distract the client from his NATs, and/or to change his attitude towards them. Other exercises are designed to promote a change of attitude towards NATs. Instead of getting ‘swallowed up’ by them, the aim is to get some distance from them, for the client to see them as ‘just thoughts’ rather than obvious truths about themselves or the world. Counting the thoughts can help – not paying any other attention to them, just counting them, with the same attitude one might have in spotting how many pigeons there are in one’s neighbourhood: ‘There’s one … and another … oh, and there’s another’! One metaphor to describe this approach is to imagine one’s stream of thoughts as a rather dirty and polluted river, with all kinds of sewage and garbage in it. Initially, your client may be like someone who has fallen into the river and is being swept along by it, surrounded by all the garbage. The new attitude is like climbing out of the river and standing on the bank, watching it all go by; the garbage is all still there, but the client is likely to be less affected by it. This is similar to the mindfulness approaches outlined in Chapter 17.
Main cognitive strategies
The bulk of a course of CBT for depression will be taken up with NATs, using the approach outlined in Chapters 8 and 9. That is, sessions will include, in varying proportions according to the stage of therapy and the client’s reaction to therapy:
CBT is, of course, not the only effective treatment for depression, and in particular, anti-depressant medication is helpful for many depressed clients. There is currently less concern about dependence and withdrawal for anti-depressants, compared to anxiolytics, and there is no conflict between pharmaceutical treatment and psychological therapy. In fact, there is some evidence that for people with more severe depression, the combination of both forms of treatment is better than either alone (e.g. Thase et al., 1997; NICE, 2009c).
Dealing with suicidal thoughts
The risk of suicide in depressed clients should not be overestimated – the vast majority of depressed clients do not commit suicide – but it clearly needs to be taken seriously, and you should respond to any sign of suicidal ideation, sometimes even if it means breaking confidentiality. For this reason, you should always be very clear at the outset of treatment that you are bound by law to break confidentiality if you think that your client is a risk to themselves (or others). Do not delay telling your client this; it is less likely to disrupt your therapeutic relationship if you disclose your ethical obligations when you begin therapy.
Professional consensus is that amongst the risk factors for suicide are the following (Peruzzi & Bongar, 1999):
Management of suicidal clients
You need to have a basic management plan in place so that you can safely continue cognitive therapy. The elements of such a plan might include the following:
Exploring and working with reasons for suicide
It is important to give clients a space in which to talk about suicidal thoughts and to approach the topic in a matter-of-fact way that gives the clear message that the topic is not off limits. You will not make someone more likely to commit suicide by asking about their suicidal thoughts, and you may have a chance to prevent suicide if the topic is in the open. Important aspects of this discussion will include:
a to escape from an unbearable life, depression etc. (‘It’s the only way out’) – this is probably the most common reason for suicide, and the most dangerous;
b to solve an external problem (e.g. to hold onto a relationship, take revenge, or elicit care);
There is some evidence both that depressed people have deficits in social problem-solving and that teaching structured problem-solving can be an effective therapy for people with depression (see, for example, Nezu, Nezu & Perri, 1989; Mynors-Wallis, Davies, Gray, Barbour & Gath, 1997; Mynors-Wallis, Gath & Baker, 2000). This may be especially useful with clients whose formulation includes something like the poor coping/hopelessness maintenance cycle outlined in Figure 12.1; it may also be helpful in dealing with suicidal ideas as outlined above.
The main steps for your client to follow in doing problem-solving are as follows:
Potential problems in treating depressed clients
The nature of depression
It is obvious – but nevertheless important to remember – that the depressed client is often negative in his thinking, lacking in drive and energy, and hopeless about the possibility of change. Depression can also result in a ‘depressing environment’: e.g. your client’s depression leads to his losing his job, or to marital difficulties, which then tend to maintain his low mood. It is therefore hardly surprising that you may find yourself struggling to engage clients. They may find it difficult to take any action, greet every suggestion with ‘That will never work’ and be tempted to give up at every real or imagined ‘failure’.
Therapists too may have difficulties in working with depression. You may find yourself ‘infected’ by the client’s pessimism, silently thinking that he is right and things are indeed as bad as he thinks they are. Of course, that could be an accurate view, but you should be careful about buying into it too easily without a great deal of evidence. Although it may be the case that your client is facing genuine difficulties and at least some of his negative thoughts are accurate, there is usually still room for questioning and looking for alternatives. It may be bad, but it is usually not so bad that 100% of people would feel as the client does, so there must be some room for alternative views. On the other hand, it is also important not to get so bound up with being so sceptical and positive that you come across as unempathic or impatient. Clients need to know that you understand where they’re coming from before you start trying to help them see where they might go to. Kennerley, Mueller and Fennell (2010) have some ideas on managing the impact of such difficulties on yourself. The problems described here may be particularly difficult when working with chronic and severe depression (see Moore & Garland (2003) for a useful guide to such work).
Hopelessness and ‘Yes, buts’
As we have just noted, most depressed clients will inevitably bring to therapy some of the negative thinking that pervades the rest of their lives. They will be hopeless about the possibilities of change and tend to have negative thoughts about therapy, with ‘Yes, but …’ being a common reaction to attempts to broaden their thinking. For you, as a therapist, it is important not to be too influenced by this way of thinking but to remain (realistically) optimistic and to understand that your client’s reactions to therapy are part of the depressive syndrome. Graded task assignments, as discussed earlier in this chapter, are a good way to get small successes that will help to build the client’s confidence. Behavioural experiments are also a good way to drive home verbal discussions so that new ways of thinking are not just vague theoretical possibilities but are tested out in action. Sometimes such ‘Yes buts’ reflect extremely fixed fundamental beliefs, so it may be helpful to consider some of the schema-focused strategies inChapter 17.
Depressed clients may be slowed up in their thinking and behaviour and, even if they are not, the pace of sessions and the speed of change early in treatment is likely to be slow. It is helpful if you are prepared for this, and adapt to it, but do not become discouraged by it. Monitoring progress using some measure such as the BDI (Chapter 4) may also be useful in picking up small but steady changes.
Feedback in sessions
As noted in Chapter 11, asking the client to give you feedback on a session is a standard part of CBT. However, it may be particularly important to encourage the depressed client to do this openly, because his negative bias makes it particularly likely that some words or behaviour on your part may be misinterpreted as being critical or rejecting of him. For the same reason, it is always worth noting and enquiring about any apparent decline in mood during a session: what went through your client’s mind when that happened?
Relapse is a particular problem in depression, with estimates that as many as 50% of depressed clients will relapse within two years of the end of ‘successful’ treatment. It is therefore especially important to develop a relapse plan (see Chapter 6) and perhaps also consider offering ‘continuation’ therapy at lower intensity to help maintain and consolidate gains (Vittengl, Clark & Jarret, 2010).
o perception, interpretation and recall of events all tend to be negatively biased.
o behavioural strategies such as activity scheduling
o early negative thought management strategies such as distraction
o the main cognitive work of testing negative thoughts through discussion and behavioural experiments
o relapse prevention, including possible work on dysfunctional assumptions and core beliefs.
Review and reflection:
Taking it forward:
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.
As noted in Chapter 1, a classic of cognitive therapy.
Martell, C., Addis, M., & Jacobson, N. (2001). Depression in context: strategies for guided action. New York: Norton.
The seminal book on the approach to depression known as ‘behavioural activation’, which grew out of the Jacobson dismantling study discussed in this chapter (see also Chapter 17 of this book).
Moore, R., & Garland, A. (2003). Cognitive therapy for chronic and persistent depression. Chichester: Wiley.
A very useful guide to adapting standard ‘Beckian’ CBT to the particular challenges of chronic, or treatment-resistant, depression, including helpful clinical examples.