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Cognitive Behavioural Therapy for Depression

Getting help for depression

Depression is the most common mental health disorder in the UK, with as many as 3 million people in the UK being presently diagnosed with the condition.  

Many don’t seek help.  Others seek help but are prescribed antidepressant medication.  Some seek access to Talking Therapies for Depression.

Here, we are going to look at one of the first line talking therapies for Depression, Cognitive Behavioural Therapy (CBT) and how modern CBT techniques can help alleviate the symptoms of depression and keep them gone for good.

Picture of a man looking stressed and depressed

What to expect from CBT treatment for Depression.

More and more, Depression is beginning to be understood in a much broader sense than simply being a disorder of the brain and more of a condition that that involves a combination of biological, psychological, social and cultural factors.  Despite these more holistic understandings, antidepressant medication prescriptions have actually gone through the roof over the past 10 years.  In the UK, the number of people who have been prescribed antidepressant tablets has doubled over the past 10 years, despite an increase in the availability of effective talking therapies.

Cognitive Behavioural Therapy has been shown to be as effective a treatment for Depression as antidepressant medication, but people are often unsure of what to expect when they begin CBT treatment.  The avoidance, reduced activity, negative thoughts and low motivation that people experience as part of the depression often means that they will delay or avoid seeking help entirely.

I write this guide here so that you know exactly what to expect from CBT therapy for Depression, to break down some of the concerns or worries you may have about treatment.

If you decide that you want to get help from us, either face to face or online, call us on 07887 701176 or email enquiries@accesscbt.co.uk

What is Depression?

Depression is the term generally given to a set of symptoms in which the sufferer experiences feelings of sadness or loss for an extended period of time.  In addition, they will tend to not find pleasure or meaning in activities that they would usually enjoy and the may find themselves reducing their activity levels or avoiding people or situations due to how they feel.

When people have depression, they often also notice changes in physical needs too.  For instance, they may find themselves struggling to sleep or eating to much or too little.  Significantly, they also experience changes in the way they think.  The majority of people who are depressed report having negative thoughts about themselves, their situation or other people.  They can often find themselves caught up in these patterns of negative thinking, making it difficult for themselves to engage with everyday tasks.

Importantly, depression can lead the sufferer to experiencing suicidal thoughts.

CBT Treatment for Depression.

There are two types of Cognitive Behavioural Therapy treatments for depression which have been shown to be effective.  The first of these, and the model upon which much of the later CBT approaches were built upon, is called the “Cognitive Model of Depression”.

The Cognitive Model of Depression works from the assumption that it is the way that we think about ourselves, the world and other people that contributes to and maintains depression.  The model suggests that we all develop a view of ourselves and the world through our experiences with it.  Early experiences in our lives lead us to form a model of how and who we are and how we can relate to our world around us.  As the world is not necessarily an easy place to live in, we develop rules and assumptions to help us through.

The Cognitive Model of Depression then goes on to suggest that if we are presented with a situation in which one of our rules or assumptions no longer fit our experience, then this will activate deeper “Core Beliefs” or “Schema”, which then give rise to the depressive symptoms.

Take a look at the example below:

Here we can see the full model of depression.  Just focusing upon the lower levels of the model we can see that the model shows that a Negative Automatic Thought, or NAT, for short has been activated in response to the “Critical Incident” of being overlooked for promotion.  The negative automatic thought, “I must just not be good enough then”, leads to changes in the individual’s behaviour (they stop trying and withdraw from work), they feel low and sad in mood, their motivation reduces and the way they think changes too.  They begin to think in ways that support this negative thought – “I always miss out on things”, “I’ll never get the promotion.”

The Cognitive Model’s main objective then is to teach you how to recognise and change any thoughts that may be keeping the depression going.  So as an example, if I have and believe the thought, “I must not be good enough then” the reduction in my work activity and withdrawal may actually contribute to and strengthen the thought.  This leads to what we call a maintenance cycle.

As we look at the upper levels of the model, we can see the levels of “Early Experiences”, “Core Beliefs” and “Rules/Assumptions.”

In this case, the model shows us that the individual’s early experiences – Being the middle child in a family of high academic and sporting achievers, not being given attention by their parents in comparison to their slightly better performing siblings – led them to develop the idea that they are not good enough.

It is important to state here that the core belief, “I’m not good enough” is not necessarily accurate or true – if anything it’s just an opinion at best – but because the belief is one that is developed at a young age, it is often relatively rigid, subjective and black and white in its nature.

Likewise, early experiences lead to beliefs about other people and the world around us.  These, coupled with our beliefs about ourselves, form what we call the “Cognitive Triad.”

Now, despite our early experiences and our beliefs about the world, ourselves and the people around us, we still need to find a way to get our needs met and to get by in the world.  For this, we then need to develop rules to get by – these are the next stage in the model.  Let’s say that we have some core beliefs like, “I’m not good enough”, “Others are neglectful” and “the world is a competitive place.”  You can see in the early experiences in the model why these beliefs were arrived at.

We then develop our rules and assumptions to ensure that our needs are met.  In our example, we see that the individual developed the rules, “If I always give 110% then I’ll succeed” and “If I fail, then it’s because I’m not good enough.”  So we go out into the world, using these rules and others as a way of interacting.

But then what if something happens in our lives that the rules or assumptions don’t account for?  For instance, what if I’m living by the rule, “If i always give 110% then I’ll succeed” and then, after giving 110% my boss points out that I’ve made a mistake at work or my partner is critical of something that I’ve done.  All of a sudden, because of this “critical incident”, my rule no longer works.  And if my rule no longer works then, I think “It’s true, I am not good enough.”  The “not good enough” core belief is activated and with this comes the changes in behaviour, emotion, thinking, motivation and physiology – the full “schema” is activated.  If my rule is repeatedly broken then the consequence is that the negative schema remains active and I can go into depression.

Treatment with the Cognitive Model of Depression

So far then, we understand how the model works, but what does this mean for treatment.  Well, the Cognitive model of Depression, as the name suggests is about changing the way we think to relieve our depression symptoms.  But there are a couple of things that the treatment model needs to do first.

Behavioural Activation for Depression is a treatment model for depression in its own right but it is also a key part of the Cognitive Model of Depression.  Behavioural activation in this model aims to address the reduced activity and lack of positive experience from activities by recording and scheduling activities in terms of how much pleasure they give us and how much of a sense of mastery.  You will be asked by your therapist to keep a record of all of the tasks that you do on a weekly basis and rate them on a 0 to 10 scale in terms of pleasure and mastery.

What we tend to find is that there are a lot of periods of either inactivity (and as such no pleasure or mastery is identified) or that many of the tasks that the individual does fail to activate any sense of pleasure or mastery.  Our job then, is to use to build upon the information in this diary to schedule activities to reduce inactivity (literally “activation”) and to work out why certain tasks don’t give a sense of pleasure or mastery and then schedule in ones that do.

It then seems logical that the more things that we do that make us feel good, the fewer opportunities that we have to feel depressed.  Of course, often it is not that simple – we may be very activated but still depressed or we’re doing the same things that we always did but no longer finding the sense of pleasure or mastery in them.  This is why working with the way we think is also very helpful, but its also important to acknowledge that changing what we do in our lives can also lead to changes in the way we think.

Follow this link to learn more about behavioural activation for depression as a treatment in its own right.

Time to consider thoughts

The next step that we take is learning to challenge negative thoughts.  There are many ways to do this, but first we need to get used to actually seeing that they are there and understanding how they relate to our emotions.  To do this we use a diary like the one below.  Follow the link to find out how to catch the negative automatic thoughts.

Once we are skilled in noticing our negative thoughts, in terms of what they are, what triggers them and what emotions they are linked to, we can then begin the process of learning to evaluate them and challenge them – this is what we call cognitive restructuring.

There are lots of ways that we can learn to challenge our thoughts.  We can label them, work out how much evidence we have for them, evaluate them in terms of how much cost or benefit they give to us, or one of many, many other techniques.  The key thing here is that we are learning not to take our negative thoughts for granted.  Even thought they may seem accurate at the time we have them, we may even really believe them, they may just not be as accurate or as helpful as we think they are.  This process lets us see them, evaluate them and change them as necessary.

In essence we are expanding the range of thinking available to us, like this…

Before thought challenging

After thought challenging

inflexible thinking
flexible vs inflexible thinking

Assumptions and Schema

As mentioned earlier, Negative automatic thoughts are linked to other types and levels of thinking: Our Core Beliefs (or Schema) and our Rules and Assumptions.  As we progress through treatment using the Cognitive Model for Depression, we are also interested in testing out and changing the validity of our rules and assumptions about the world, just like we are also interested in developing alternative Core Beliefs about ourselves and the world around us.

Behavioural Activation for Depression

Behavioural activation for depression is another CBT approach to depression which has been tested and shown to be an effective treatment.

Unlike the Cognitive Model of Depression, Behavioural Activation places less of an emphasis upon the thoughts that we have whilst we are depressed and focuses more upon the changes in our behaviour.  As mentioned earlier, when we get depressed, we tend to withdraw, isolate ourselves and avoid places, people and situations because of how we feel.

This is in part understandable.  If I am not experiencing things that make me happy, or even worse, if the things in my life are actually making me feel worse, then it is an understandable response to avoid things and to retreat to a place where I feel less unhappy.  The problem is though, while retreat from painful life events can make me feel relief in the short term, over the longer term this behaviour can cause me to miss out upon the things in life that might event make me feel good.  I back off from stressful life events, I do less, I don’t experience others things that might make me feel better and a cycle ensues.

In addition, as I reduce my activity and avoid stressors, this gives me more time to dwell upon my negative thoughts, which in turn increases my low mood.  Because I’m avoiding my problems, they also don’t get resolved meaning they stay the same or get worse.  And here we have our second “maintenance” cycle.

There are two main Behavioural Approaches to Depression treatment.

A picture of the Martell model is presented here:

Martell Behavioural Activation model

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Conclusion

This is an overview of the fundamental CBT treatments for Depression.  Other “Third Wave” offshoots of CBT such as Mindfulness-Based CBT, Acceptance and Commitment Therapy (ACT) and Compassion Focused Therapy are also rapidly demonstrating their effectiveness as treatments for Depression too and are covered elsewhere on the site.

Picture of a man looking stressed and depressed

CBT for Depression

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CBT for Anxiety

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EMDR Online

Online EMDR Therapy