What are the defining characteristics of the cognitive therapy approach to depression?Judith Beck:
The hallmark of cognitive therapy is understanding clients’ reactions---emotional and behavioral---in terms of how they interpret situations. For example, currently I’m treating a severely depressed client I’ll call Mary, who basically sits on the couch for most of the day, feeling hopeless and sad. Even though she understands that she’d be better off if she were to become more active, she can’t overcome her profound lethargy. She continually has thoughts like This apartment is so messy. Nothing’s put away. What’s wrong with me? I should get up and do something, but it’ll just be a drop in the bucket. What’s the point?
No wonder she feels so depressed and hopeless and just stays on the couch.
The repeated themes in people’s thinking and behavior always make sense once we understand the basic way they view themselves, their world, and other people. Mary, for example, sees herself as helpless and incompetent, a “complete failure,” and that pervades her moment-to-moment experience. Not only does she feel unable to get off the couch, but she also believes that she won’t be able to solve any of her problems and that nothing, including therapy, can help.That kind of outlook is one of the biggest problems in working with depressed clients. How do you begin trying to work with someone who seems so hopeless?Beck:
First, I reinforced her for being open about her skepticism: “Mary, it’s good you told me that.” Then I reinforced the cognitive model by saying, “That’s an interesting thought. You don’t think that therapy can help. How much do you believe that?” Then I proposed we test the thought: “Mary, I’d like us to figure out whether that thought is likely to be 100 percent true or 0 percent true or someplace in the middle. Is it okay if we take a look at it?”
I asked Mary several questions. What evidence did she have that the thought was or wasn’t true? Was there another way of looking at this situation? What was the effect of telling herself this over and over? Following our discussion, I asked Mary what she thought would be important to remember.Cognitive therapy still hasn’t achieved widespread acceptance among many clinicians in private practice, who complain that it’s too structured and restrictive. Why so much emphasis on structure? Beck:
First, people who think cognitive therapy is too structured and restrictive have a fundamental misunderstanding about the treatment. They don’t understand that treatment needs to be adapted for the individual. Most depressed clients appreciate the basic structure because it makes sense to them, and they like the idea that we’re going to help them solve their problems, step-by-step. When clients express a preference to be less structured, the therapist accommodates their desire.
Why do we structure the session in the first place? Every minute in a session is precious, and we want to maximize the time we have to help clients learn to deal with the issues that are most important to them. At the beginning of sessions, we do a mood check (so we can make sure that clients are improving), get an update (including a review of their action plan from the previous session), and find out what problem or problems they most want help in solving. Then we help clients prioritize their issues and ask them which one they’d like to start with.
In the middle of sessions, we discuss their most pressing problems and collaboratively decide where to start working. At the end of sessions, we ask clients for feedback. What did they think of the session? Was there anything they thought we didn’t understand? Is there anything they want to do differently next time?The cognitive approach seems to pay a lot of attention to therapeutic homework. Why is that so important?Beck:
We tell clients that it’s not enough just to talk for 45 to 50 minutes a week in therapy sessions. The way people actually get better is by making small changes in their thinking and behavior every day. Homework is a big part of helping clients learn to be their own therapist. It should be set collaboratively and may include implementing solutions to problems, reviewing responses to key automatic thoughts, evaluating and responding to new automatic thoughts, and practicing behavioral skills.With the rates of relapse for depression being so high, what’s the role of relapse prevention in your work?Beck:
Relapse prevention begins in the first session, when we tell clients that we want to help them become their own therapists. We’re careful not only to use techniques with clients, but also to teach them how to use these techniques themselves, so they’ll have a toolkit for life.
Toward the end of treatment, we ask clients to write a list of early warning signals they’ll use to detect if they’re starting to get depressed again. Then we help them develop a written plan of what they should do if that happens. We also teach them how to hold a self-therapy session with themselves. We try to taper sessions so clients gradually end treatment, and if possible, we schedule booster sessions after treatment is over. Overall, the research shows that clients who’ve had cognitive therapy have about half the relapse rate as those who only take medication.This blog is excerpted from “The Power of Small Changes”. The full version is available in the Nov/Dec 2014 issue. To subscribe, click here. >>Want to read more articles like this? Subscribe to Psychotherapy Networker Today!>>