Depression-Focused Psychotherapies: Cognitive Therapy
CT developed between the late 1950s and mid-1970s as a result of the work of Aaron T. Beck (1967, 1976).
CT of depression posits the involvement of three types of problems in cognition. The first type of cognitive dysfunction is reflected by the fact that depressed persons spend a disproportionate amount of time thinking gloomy or unpleasant thoughts about themselves, their world, and their future. Beck (1976) referred to the content of thoughts in these three domains—self, world, and future—as the cognitive triad. Cognitions that are particularly relevant are those that occur almost instantaneously with the worsening of depressed moods, which are referred to as automatic negative thoughts. These negative cognitions provide the gateway for the cognitive therapist to understand the depressed patient’s phenomenological world.
Shared Features of Depression-Focused Psychotherapies
The second type of cognitive dysfunction involves errors in information processing, including overgeneralization, excessive personalization, selective abstraction, emotional reasoning, and all-or-none thinking (for an expanded description, see Burns 1980). Such difficulties are characteristically state-dependent—that is, only apparent during the depressive episode. Mood-dependent changes in information processing may be heuristically understood as serving to clarify and intensify the guiding beliefs that characterize the patient’s phenomenological world. In this way, the mistaken conclusions resulting from errors in information processing serve to reinforce and maintain changes in self-esteem and pessimism that typify the depressive state.
The third type of cognitive dysfunction involves dysfunctional attitudes and depressogenic schemas. Both attitudes and schemas are considered to be ultimately accessible through questioning techniques, as illustrated by the use of the Socratic method or guided discovery. The personal meaning revealed in a series of automatic thoughts is thus used to infer deeper patterns of cognitive organization. Dysfunctional attitudes not only are associated with more extreme or intense reactions to life stress but also appear to confer a greater risk of encountering new adversities.
CT thus is more traditionally oriented than behavior therapy because dysfunctional attitudes and schemas are unconscious and nonobservable constructs. These depressogenic structures are presumed to result from adverse early experiences. In persons prone to depression, schemas representing excessive interpersonal dependence or perfectionistic demands are theorized to be “silent” during times of a stable romantic relationship or a high vocational attainment. However, they are “activated” in response to specific, matching adversities. The activation of a pathological schema is hypothesized to induce mood-dependent changes in memory, information processing, and automatic negative thoughts. Stress-diathesis interactions may explain why only some individuals become depressed after a stressor such as divorce or unemployment.
Like IPT and the behavioral therapies, CT was developed as a short-term model of treatment. More recent refinements in CT have been introduced in the areas of case formulation, treatment of personality pathology, treatment of inpatients, and treatment of chronic depression. Provisions are made for concomitant use of antidepressant medication in both outpatien and inpatient CT manuals. The technical fidelity and quality of CT sessions may be measured by an objective tool, the Cognitive Therapy Scale, although the cross-site reliability of this scale needs to be ensured.
In addition to its more elaborate theoretical orientation, CT also differs from most forms of behavior therapy with respect to the detail of its guidelines for working with depressed patients. These guidelines include a unique approach to the therapeutic relationship, termed collaborative empiricism, which directs the therapist to assume the role of a coach or teacher in addition to his or her providing the more traditional nonspecific elements of understanding and support. Through this model of interaction the therapist and patient develop stepwise goals to reduce symptoms, improve management of pressing day-to-day problems, and increase morale. Collaboration is explicitly fostered via the liberal use of feedback and questioning to ensure that the patient understands the material being covered. Compared with the process of more traditional dynamic therapies, CT requires therapists to be significantly more active within sessions. Conversely, a premature or excessive focus on correcting cognitive errors may strain the therapeutic alliance.
The therapist introduces each new technique or intervention as a hypothesized means to help bring about therapeutic change. Explicit homework assignments and the demonstration of methods and techniques within sessions are employed to facilitate the patient’s participation. Each session utilizes a coherent structure in which an agenda is set, homework is reviewed, attention is given to one or two key problem areas, and feedback is obtained. Some evidence indicates that the therapist’s ability to structure and pace sessions and to consistently integrate homework assignments is predictive of better outcomes.
Early in the course of therapy, particularly with more severely depressed patients, there is typically a greater emphasis on behavioral techniques. For example, daily monitoring of moods and activities is used to increase participation in rewarding behaviors and to establish functional relationships between moods and automatic thoughts. Similarly, stepwise graded task assignments are used to address problems that are perceived as overwhelming.
Slowly, and at a pace appropriate to each patient’s ability to use abstract thought, the therapy moves toward eliciting and testing the accuracy of automatic thoughts and developing rational alternatives. Therapeutic strategies, such as the use of written responses to stereotypic automatic negative thoughts (“coping cards”) and a printed, five-column form known as the Daily Record of Dysfunctional Thoughts, are used to teach patients to begin to challenge their negative cognitions. Patients are also encouraged to keep their thought records as part of a journal or notebook so that a coherent summary of the course of therapy is readily available. Each session ends with a new homework assignment that builds logically on the material just covered.
It is important to distinguish more simplistic models of cognitive intervention, such as verbal persuasion, from the actual process of CT. In contrast to persuasion, in which the “expert” advocates the “correct” position, CT emphasizes guided discovery of logical errors and alternative interpretations. The fact that more positive alternative conclusions can typically be identified and validated is at the heart of CT.
One misperception about CT is that it minimizes affect and negates the personal significance of serious setbacks, recommending Pollyanna-like optimism in the face of adversity. Rather, when CT is conducted skillfully, the patient’s emotional reaction to a significant event is respectfully and empathically understood in relation to his or her thoughts about self, world, and future. From the therapist’s perspective, the personal meaning of the stressor may be found to be exaggerated when the patient’s automatic negative thoughts are examined more objectively. Through the guided discovery process, the therapist helps the patient elicit the chain of associated thoughts in order to clarify a more exaggerated set of personal conclusions. This “downward arrow” technique may reveal, for example, that a person who has been fired from a job for poor performance has concluded, “I have failed at everything.” Rather, objective examination of the situation might reveal that the job failure was partly attributable to being undertrained and partly the result of worsening depression. Previous examples of success in the workplace may be identified to help counteract depressive recall. The problems resulting from being fired also need to be assessed, and a plan to address these problems can be developed. CT thus differs from dynamic or experiential therapies in that affect is specifically used to lead to a cognitive process by which depressed patients learn to solve problems and gain greater control over dysphoric moods.
It is also believed to be incumbent on the cognitive therapist to help patients identify patterns and themes associated with depressive vulnerability before terminating treatment. In this regard, the final sessions of CT may be devoted to “diagnosing” pathological schemas and specific skills deficits and developing longer-range self-help plans to address these problems. Modification of such vulnerability is hypothesized to convey a more enduring prophylactic effect. It remains controversial whether such decreased vulnerability is better understood as the result of development of a compensatory set of skills (i.e., to offset a persistently pathological schema) or the actual revision of schemas.
Revision date: July 5, 2011
Last revised: by Jorge P. Ribeiro, MD