COGNITIVE MODELS OF TREATING DEPRESSION
The two cognitive models of depression view particular thoughts as the crucial
cause of depressive symptoms. The first, developed by Aaron T. Beck,
derives mainly from extensive therapeutic experience with depressed patients,
and it views depression as caused by negative thoughts about the self,
about ongoing experience, and about the future. The second, developed by
Martin E.P. Seligman, derives mainly from experiments with dogs, rats, and
mildly depressed people, and it views depression as caused by the expectation
of future helplessness. A depressed person expects bad events to occur
and believes that there is nothing he can do to prevent them from occurring.
Beck's Cognitive Theory of Depression
Aaron T. Beck (along with Albert Ellis) founded a new type of therapy,
called cognitive therapy. For Beck, two mechanisms, the cognitive triad and errors in logic, produce depression.
THE COGNITIVE TRIAD
The cognitive triad consists of negative thoughts about the self,
about ongoing experience, and about the future.
The negative thoughts about the self consist of the depressive's belief that he
is defective, worthless, and inadequate. The symptom of low self-esteem
derives from his belief that he is defective. When he has unpleasant experiences,
he attributes them to personal unworthiness. Since he believes he is
defective, he believes that he will never attain happiness.
The depressive's negative thoughts about experience consist in his interpretation
that what happens to him is bad. He misinterprets neutral interaction
with people around him as meaning defeat. He misinterprets small
obstacles as impassable barriers. Even when there are more plausible positive
views of his experience, he is drawn to the most negative possible interpretation
of what has happened to him. Finally, the depressive's negative
view of the future is one of hopelessness. When he thinks of the future, he
believes that the negative things that are happening to him now will continue
unabated because of his personal defects. The following case illustrates
how a depressive person may negatively interpret her experiences:
Stella, a thirty-six-year-old depressed woman, had withdrawn from the tennis
games she had previously enjoyed. Instead, her daily behavior pattern consisted of "sleeping and trying to do the housework I've neglected." Stella firmly believed
that she was unable to engage in activities as "strenous" as tennis and that she had become so poor at tennis that no one would ever want to play with her. Her husband arranged for a private tennis lesson in an attempt to help his wife overcome her depression. She reluctantly attended the lesson and appeared to be "a different person" in the eyes of her husband. She stroked the ball well and was agile in following instructions. Despite her good performance during the lesson, Stella concluded that her skills had "deteriorated" beyond the point at which lessons would do any good. She misinterpreted her husband's positive response to her lesson as an indication of how bad her game had become because in her view, "He thinks I'm so hopeless that the only time I can hit the ball is when I'm taking a lesson."
She rejected the obvious reason for her husband's enthusiasm in favor of an explanation derived
from her negative image of herself. She also stated that she didn't enjoy the tennis session
because she wasn't "deserving" of any recreation time. (Adapted from Beck et al., 1979.)
Stella's depression exemplifies the negative triad: (I) She believed that her
tennis abilities had deteriorated (negative view of self), (2) she misinterpreted
her husband's praise as indication of how poor her game was (negative
view of experience), and (3) she believed that no one would ever want to
play with her again (negative view of the future). Her motivational and cognitive
symptoms stemmed from her negative cognitive triad. Her passivity
(giving up tennis for sleeping and housework) resulted from her hopelessness
about her abilities. Her cognitive symptoms were the direct expressions
of her negative views of herself, her experience, and her future. Beck also
claims that the other two classes of depressive symptoms-emotional and
physical-result from the depressive's belief that he is doomed to failure.
ERRORS IN LOGIC
Systematic errors in logic are Beck's second mechanism
of depression. According to Beck, the depressive makes five different
logical errors in thinking, and each of these darkens his experiences: arbitrary
inference, selective abstraction, over generalization, magnification and
minimization, and personalization.
Arbitrary inference refers to drawing a conclusion when there is little or
no evidence to support it. For example, an intern became discouraged when
she received an announcement which said that in the future all patients
worked on by interns would be reexamined by residents. She thought, incorrectly, "The chief
doesn't have any faith in my work." Selective abstraction
consists of focusing on one insignificant detail while ignoring the more
important features of a situation. In one case, an employer praised an employee
at length about his secretarial work. Midway through the conversation,
the boss suggested that he need not make extra carbon copies of her
letters anymore. The employee's selective abstraction was, "The boss is dissatisfied
with my work." In spite of all the good things said, only this was remembered.
Over generalization refers to drawing global conclusions about worth,
ability, or performance on the basis of a single fact. Consider a man who
fails to fix a leaky faucet in his house. Most husbands would call a plumber
and then forget it. But the depressive will overgeneralize and may go so far as
to believe that he is a poor husband. Magnification and minimization are
gross errors of evaluation, in which small bad events are magnified and large
good events are minimized. The inability to find the right color shirt is considered
a disaster, but a large raise and praise for his good work are considered
trivial. And lastly, personalization refers to incorrectly taking
responsibility for bad events in the world. A neighbor slips and falls on her
own icy walk, but the depressed next-door neighbor blames himself unremittingly
for not having alerted her to her icy walk and for not insisting that
she shovel it.
Cognitive Therapy
Beck's cognitive theory of depression considers that depression is caused by
negative thoughts of self, ongoing experience, and future, and by errors in
logic. Cognitive therapy for depression attempts to counter these cognitions
(Beck, 1967; Beck, Rush, Shaw, and Emery, 1979). Its aim is to identify and
correct the distorted thinking and dysfunctional assumptions underlying
depression (Rehm, 1977; Beck et al., 1979). In addition, the patient is taught
to conquer problems and master situations that he previously believed were
insuperable. Cognitive therapy differs from most other forms of psychotherapy.
In contrast to the psychoanalyst, the cognitive therapist is continually
active in order to guide the patient into reorganizing his thinking and his
actions. The cognitive therapist talks a lot and is directive.
She argues with the patient. She persuades; she cajoles; she leads. Beck
claims that nondirective classical psychoanalytic techniques, such as free association, cause
depressives to "dissolve in the morass of their negative
thinking." Cognitive therapy also contrasts with psychoanalysis by being
centered in the present. Childhood problems are rarely discussed, rather the
major focus is the patient's current thoughts and feelings.
DOES COGNITIVE THERAPY WORK ON DEPRESSION?
Does the therapy that we have just outlined alleviate unipolar depression?
Forty-four depressed outpatients, mostly white, college-educated, and in their
mid-thirties, were randomly assigned either to individual cognitive therapy or to
therapy with tricyclic antidepressants for twelve weeks (Rush, Beck, Kovacs, and
Hollon, 1977; Kovacs, Rush, Beck, and Hollon, 1981). Their depressions were
quite severe: on the average, the current episode of depression had lasted for
twelve months, and patients had already seen two previous therapists unsuccessfully.
All the patients were moderately to severely depressed at the start of treatment,
and three-quarters of them were suicidal. During the course of therapy, the
patients in the cognitive therapy group had a maximum of twenty sessions, and the patients in
the drug group were given 100-250 mg of imipramine (a tricyclic)
daily, plus twelve brief sessions with the therapist who had prescribed the drugs.
By the end of treatment, both groups had improved according to both self-report
and therapist ratings of depression. Only one of the nineteen patients assigned
to cognitive therapy had dropped out, whereas eight of the twenty-five
assigned to drug therapy had dropped out. This is not surprising, since there is
always notable attrition due to side effects and reluctance to take drugs in drug
treatment. Of the cognitive therapy patients, 79 percent showed marked improvement or
complete remission, but only 20 percent of the drug patients
showed such a strong response. Follow-up at three months, six months, and twelve months after
treatment indicated that both groups maintained their improvement.
The group that had received cognitive therapy, however, continued to be less
depressed than the group that had received drug therapy. In addition, the cognitive group had
half the relapse rate of the drug group.
While this result is tentative, it is promising. If confirmed by additional studies with
larger and more typical groups of patients, and a larger range of drug dosage
and drug monitoring, there may be reason to believe that either cognitive therapy
alone or in conjunction with drug therapy is the optimal treatment for unipolar depression (Becker and Schuckit, 1978).
Cognitive therapy uses such behavioral therapy techniques as activity
raising, graded task assignment, and assertiveness training against depressive
symptoms. But in cognitive therapy, these techniques for changing behavioral
symptoms are just tools for changing thoughts and assumptions
that are seen as the underlying causes of depressed behavior. So, for example,
the cognitive therapist believes that teaching a depressive to behave assertively
works, only insofar as it changes what the depressive believes about
his own abilities and his future.
There are five specific cognitive therapy techniques: detecting automatic
thoughts, reality testing automatic thoughts, training in reattribution,
searching for alternatives, and changing depress genic assumptions.
DETECTION OF AUTOMATIC THOUGHTS
Beck argues that there are discrete,
negative sentences that depressed patients say to themselves quickly
and habitually. These automatic thoughts maintain depression. Cognitive
therapy helps patients to identify such automatic thoughts. Here is a case in
which the patient had been unaware of her automatic thoughts; A mother of three found that
her depression was at its worst from seven to nine
in the morning when she prepared breakfast for her children. She was unable to
explain this until she was taught to record her thoughts in writing as they occurred.
"As a result, she discovered she consistently compared herself with her mother,
whom she remembered as irritable and argumentative in the morning. When her
children misbehaved or made unreasonable requests, the patient often thought,
'Don't get angry, or they'll resent you,' with the result that she typically ignored
them. With increasing frequency, however, she 'exploded' at the children and
then thought, 'I'm worse them my mother ever was. I'm not fit to care for my children.
They'd be better off if I were dead.' " (Becket al., 1979)
REALITY TESTING AUTOMATIC THOUGHTS
Once the patient has learned to identify such thoughts, the cognitive therapist engages in a
dialogue with the patient in which evidence for and against the thoughts is scrutinized. This is
not an attempt to induce spurious optimism, rather to encourage the patient to use the
reasonable standards of self-evaluation that
Non-depressed people use. The mother who thought she was unfit would be
encouraged to remember that her children were flourishing in school, partly
as a result of her tutoring them. Similarly a young student despondent over
the belief that she would not get into a particular college was taught to criticize
her automatic negative thoughts.
THERAPIST: Why do you think you won't be able to get into the university of
your choice?
PATIENT: Because my grades were really not so hot.
THERAPIST: Well, what was your grade average?
PATIENT: Well, pretty good up until the last semester in high school.
THERAPIST: What was your grade average in general?
PATIENT: A's and B's.
THERAPIST: Well, how many of each?
PATIENT: Well, I guess almost all of my grades were A's, but I got terrible grades
in my last semester.
THERAPIST: What were your grades then?
PATIENT: I got two A's and two B's,
THERAPIST: SO your grade average would seem to me to come to almost all A's, Why don't
you think you'll be able to get into the university?
PATIENT: Because of competition being so tough.
THERAPIST: Have you found out what the average grades are for admission to
the college?
PATIENT: Well, somebody told me that a B+ average should suffice.
THERAPIST: Isn't your average better than that?
PATIENT: I guess so.
(Becket aI., 1979)
NOTE: By learning to scrutinize and criticize her automatic thoughts and marshaling
evidence against them, the patient undermines her negative automatic
thoughts, and they wane.
REATTRIBUTION TRAINING
Depressed patients tend to blame themselves for bad events for which they are not, in fact, responsible. To counteract such irrational blame, the therapist and the patient review the events, applying the standards of non-depressed individuals in order to come up with an assignment of blame. The point here is not to absolve the patient of blame, but rather to let him see that there may be other factors besides his own incompetence that contribute to a bad event.
A fifty-one-year-old bank manager in a state of deep depression believed he was
ineffective in his job. His therapy session proceeded as follows:
PATIENT: I can't tell you how much of a mess I've made of things. I made another major error
in judgment which should cost me my job.
THERAPIST: Tell me what the error in judgment was.
PATIENT: I approved a loan which fell through completely. I made a very poor
decision.
THERAPIST: Can you recall the specifics about the decision?
PA TIENT: Yes. I remember it looked good on paper, good collateral, good credit
rating, but I should have known that there was going to be a problem.
THERAPIST: Did you have all the pertinent information at the time of your decision?
PATIENT: Not at the time, but I sure found out six weeks later. I'm paid to make
profitable decisions, not to give the bank's money away.
THERAPIST: I understand your position. But I'd like to review the information
which you had at the time your decision was required, not six weeks after the decision had been made.
~~~~~~~~
When the patient and the therapist reviewed this information, they concluded
that the patient had made his judgment on sound banking principles. He recalled
that he had even made an intensive check into the client's financial background,
which he had forgotten (Beck et aI., 1979).
Such reattribution training enables patients to find sources of blame other
than themselves, and it thereby raises their low self-esteem.
THE SEARCH FOR ALTERNATIVES
A fourth technique of cognitive therapy
attacks the patient's closed system in which all problems are seen as unsolvable.
Alternative solutions to the problems are explored and a course of action set.
A twenty-two-year-old graduate student had been given a C on his paper by his
English professor and was convinced that he was "a reject." The therapist offered
alternative interpretations for the C, other than this being proof that "he couldn't
make it in school." Each alternative was rated by the patient.
The rating simply consisted of proportions of 100 percent that would represent
the degree of "believability" of each explanation. The listing in decreasing order
of believability went as follows:
1. "I'm a reject who doesn't have any ability in English." 95%
2. "The grade was not very different from that of other students." 3%
3. "The professor provided the comments to help with future essays and therefore thinks I have some ability." 2%
Fortunately, the therapist convinced the patient to get some more information
before he withdrew from the course. He encouraged the patient to call his professor from his
office. On the telephone, the patient found out that (1) the average class grade was a C, and (2)
the professor thought that although the style of the essay was "wanting," the content was
"promising." The professor suggested that they have a further discussion to explain his
criticisms. As a result of this new information, the patient became more animated and cheerful.
Instead of viewing himself as a "reject," he readily agreed that he required concrete instruction
in writing style. He decided to get some tutoring and to complete the term rather than withdraw
from the course. (Adapted from Beck et al., 1979.)
The patient believed that getting a C meant he was incompetent. Alternative
explanations were not credible to him and he was prepared to act
based on his most catastrophic interpretation of the situation. Once alternatives
were furnished and the patient gained realistic information, both the
depressed mood and the self-destructive actions of the patient were reversed.
CHANGING DEPRESSOGENIC ASSUMPTIONS
The final technique of cognitive
therapy is the explicit change of depress genic assumptions (Ellis,
1962). Beck outlines six assumptions that depressed individuals base their
life upon, thereby predisposing themselves to sadness, despair, and disappointment:
(1) in order to be happy, I have to be successful in whatever I
undertake; (2) to be happy, I must be accepted by all people at all times; (3) if
I make a mistake, it means I am inept; (4) I can't live without love; (5) if
somebody disagrees with me, it means he doesn't like me; and (6) my value
as a person depends on what others think of me. When the patient and therapist
identify one of these assumptions, it is vigorously attacked. The validity
of the assumption is examined, counterarguments are marshaled,
plausible alternative assumptions are presented, and the disastrous consequences of holding the
assumptions are exposed.
~~~~~~~~~~~~~~~~~~~~~~
Treating:
Depression and Suicide
Post-Traumatic Stress Disorder (PTSD)
Social Anxiety
Generalized Anxiety
Panic Disorder
Major Depression Disorder
Agoraphobia
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
For the Therapy I recommend click here:
The Liberator Method
cause of depressive symptoms. The first, developed by Aaron T. Beck,
derives mainly from extensive therapeutic experience with depressed patients,
and it views depression as caused by negative thoughts about the self,
about ongoing experience, and about the future. The second, developed by
Martin E.P. Seligman, derives mainly from experiments with dogs, rats, and
mildly depressed people, and it views depression as caused by the expectation
of future helplessness. A depressed person expects bad events to occur
and believes that there is nothing he can do to prevent them from occurring.
Beck's Cognitive Theory of Depression
Aaron T. Beck (along with Albert Ellis) founded a new type of therapy,
called cognitive therapy. For Beck, two mechanisms, the cognitive triad and errors in logic, produce depression.
THE COGNITIVE TRIAD
The cognitive triad consists of negative thoughts about the self,
about ongoing experience, and about the future.
The negative thoughts about the self consist of the depressive's belief that he
is defective, worthless, and inadequate. The symptom of low self-esteem
derives from his belief that he is defective. When he has unpleasant experiences,
he attributes them to personal unworthiness. Since he believes he is
defective, he believes that he will never attain happiness.
The depressive's negative thoughts about experience consist in his interpretation
that what happens to him is bad. He misinterprets neutral interaction
with people around him as meaning defeat. He misinterprets small
obstacles as impassable barriers. Even when there are more plausible positive
views of his experience, he is drawn to the most negative possible interpretation
of what has happened to him. Finally, the depressive's negative
view of the future is one of hopelessness. When he thinks of the future, he
believes that the negative things that are happening to him now will continue
unabated because of his personal defects. The following case illustrates
how a depressive person may negatively interpret her experiences:
Stella, a thirty-six-year-old depressed woman, had withdrawn from the tennis
games she had previously enjoyed. Instead, her daily behavior pattern consisted of "sleeping and trying to do the housework I've neglected." Stella firmly believed
that she was unable to engage in activities as "strenous" as tennis and that she had become so poor at tennis that no one would ever want to play with her. Her husband arranged for a private tennis lesson in an attempt to help his wife overcome her depression. She reluctantly attended the lesson and appeared to be "a different person" in the eyes of her husband. She stroked the ball well and was agile in following instructions. Despite her good performance during the lesson, Stella concluded that her skills had "deteriorated" beyond the point at which lessons would do any good. She misinterpreted her husband's positive response to her lesson as an indication of how bad her game had become because in her view, "He thinks I'm so hopeless that the only time I can hit the ball is when I'm taking a lesson."
She rejected the obvious reason for her husband's enthusiasm in favor of an explanation derived
from her negative image of herself. She also stated that she didn't enjoy the tennis session
because she wasn't "deserving" of any recreation time. (Adapted from Beck et al., 1979.)
Stella's depression exemplifies the negative triad: (I) She believed that her
tennis abilities had deteriorated (negative view of self), (2) she misinterpreted
her husband's praise as indication of how poor her game was (negative
view of experience), and (3) she believed that no one would ever want to
play with her again (negative view of the future). Her motivational and cognitive
symptoms stemmed from her negative cognitive triad. Her passivity
(giving up tennis for sleeping and housework) resulted from her hopelessness
about her abilities. Her cognitive symptoms were the direct expressions
of her negative views of herself, her experience, and her future. Beck also
claims that the other two classes of depressive symptoms-emotional and
physical-result from the depressive's belief that he is doomed to failure.
ERRORS IN LOGIC
Systematic errors in logic are Beck's second mechanism
of depression. According to Beck, the depressive makes five different
logical errors in thinking, and each of these darkens his experiences: arbitrary
inference, selective abstraction, over generalization, magnification and
minimization, and personalization.
Arbitrary inference refers to drawing a conclusion when there is little or
no evidence to support it. For example, an intern became discouraged when
she received an announcement which said that in the future all patients
worked on by interns would be reexamined by residents. She thought, incorrectly, "The chief
doesn't have any faith in my work." Selective abstraction
consists of focusing on one insignificant detail while ignoring the more
important features of a situation. In one case, an employer praised an employee
at length about his secretarial work. Midway through the conversation,
the boss suggested that he need not make extra carbon copies of her
letters anymore. The employee's selective abstraction was, "The boss is dissatisfied
with my work." In spite of all the good things said, only this was remembered.
Over generalization refers to drawing global conclusions about worth,
ability, or performance on the basis of a single fact. Consider a man who
fails to fix a leaky faucet in his house. Most husbands would call a plumber
and then forget it. But the depressive will overgeneralize and may go so far as
to believe that he is a poor husband. Magnification and minimization are
gross errors of evaluation, in which small bad events are magnified and large
good events are minimized. The inability to find the right color shirt is considered
a disaster, but a large raise and praise for his good work are considered
trivial. And lastly, personalization refers to incorrectly taking
responsibility for bad events in the world. A neighbor slips and falls on her
own icy walk, but the depressed next-door neighbor blames himself unremittingly
for not having alerted her to her icy walk and for not insisting that
she shovel it.
Cognitive Therapy
Beck's cognitive theory of depression considers that depression is caused by
negative thoughts of self, ongoing experience, and future, and by errors in
logic. Cognitive therapy for depression attempts to counter these cognitions
(Beck, 1967; Beck, Rush, Shaw, and Emery, 1979). Its aim is to identify and
correct the distorted thinking and dysfunctional assumptions underlying
depression (Rehm, 1977; Beck et al., 1979). In addition, the patient is taught
to conquer problems and master situations that he previously believed were
insuperable. Cognitive therapy differs from most other forms of psychotherapy.
In contrast to the psychoanalyst, the cognitive therapist is continually
active in order to guide the patient into reorganizing his thinking and his
actions. The cognitive therapist talks a lot and is directive.
She argues with the patient. She persuades; she cajoles; she leads. Beck
claims that nondirective classical psychoanalytic techniques, such as free association, cause
depressives to "dissolve in the morass of their negative
thinking." Cognitive therapy also contrasts with psychoanalysis by being
centered in the present. Childhood problems are rarely discussed, rather the
major focus is the patient's current thoughts and feelings.
DOES COGNITIVE THERAPY WORK ON DEPRESSION?
Does the therapy that we have just outlined alleviate unipolar depression?
Forty-four depressed outpatients, mostly white, college-educated, and in their
mid-thirties, were randomly assigned either to individual cognitive therapy or to
therapy with tricyclic antidepressants for twelve weeks (Rush, Beck, Kovacs, and
Hollon, 1977; Kovacs, Rush, Beck, and Hollon, 1981). Their depressions were
quite severe: on the average, the current episode of depression had lasted for
twelve months, and patients had already seen two previous therapists unsuccessfully.
All the patients were moderately to severely depressed at the start of treatment,
and three-quarters of them were suicidal. During the course of therapy, the
patients in the cognitive therapy group had a maximum of twenty sessions, and the patients in
the drug group were given 100-250 mg of imipramine (a tricyclic)
daily, plus twelve brief sessions with the therapist who had prescribed the drugs.
By the end of treatment, both groups had improved according to both self-report
and therapist ratings of depression. Only one of the nineteen patients assigned
to cognitive therapy had dropped out, whereas eight of the twenty-five
assigned to drug therapy had dropped out. This is not surprising, since there is
always notable attrition due to side effects and reluctance to take drugs in drug
treatment. Of the cognitive therapy patients, 79 percent showed marked improvement or
complete remission, but only 20 percent of the drug patients
showed such a strong response. Follow-up at three months, six months, and twelve months after
treatment indicated that both groups maintained their improvement.
The group that had received cognitive therapy, however, continued to be less
depressed than the group that had received drug therapy. In addition, the cognitive group had
half the relapse rate of the drug group.
While this result is tentative, it is promising. If confirmed by additional studies with
larger and more typical groups of patients, and a larger range of drug dosage
and drug monitoring, there may be reason to believe that either cognitive therapy
alone or in conjunction with drug therapy is the optimal treatment for unipolar depression (Becker and Schuckit, 1978).
Cognitive therapy uses such behavioral therapy techniques as activity
raising, graded task assignment, and assertiveness training against depressive
symptoms. But in cognitive therapy, these techniques for changing behavioral
symptoms are just tools for changing thoughts and assumptions
that are seen as the underlying causes of depressed behavior. So, for example,
the cognitive therapist believes that teaching a depressive to behave assertively
works, only insofar as it changes what the depressive believes about
his own abilities and his future.
There are five specific cognitive therapy techniques: detecting automatic
thoughts, reality testing automatic thoughts, training in reattribution,
searching for alternatives, and changing depress genic assumptions.
DETECTION OF AUTOMATIC THOUGHTS
Beck argues that there are discrete,
negative sentences that depressed patients say to themselves quickly
and habitually. These automatic thoughts maintain depression. Cognitive
therapy helps patients to identify such automatic thoughts. Here is a case in
which the patient had been unaware of her automatic thoughts; A mother of three found that
her depression was at its worst from seven to nine
in the morning when she prepared breakfast for her children. She was unable to
explain this until she was taught to record her thoughts in writing as they occurred.
"As a result, she discovered she consistently compared herself with her mother,
whom she remembered as irritable and argumentative in the morning. When her
children misbehaved or made unreasonable requests, the patient often thought,
'Don't get angry, or they'll resent you,' with the result that she typically ignored
them. With increasing frequency, however, she 'exploded' at the children and
then thought, 'I'm worse them my mother ever was. I'm not fit to care for my children.
They'd be better off if I were dead.' " (Becket al., 1979)
REALITY TESTING AUTOMATIC THOUGHTS
Once the patient has learned to identify such thoughts, the cognitive therapist engages in a
dialogue with the patient in which evidence for and against the thoughts is scrutinized. This is
not an attempt to induce spurious optimism, rather to encourage the patient to use the
reasonable standards of self-evaluation that
Non-depressed people use. The mother who thought she was unfit would be
encouraged to remember that her children were flourishing in school, partly
as a result of her tutoring them. Similarly a young student despondent over
the belief that she would not get into a particular college was taught to criticize
her automatic negative thoughts.
THERAPIST: Why do you think you won't be able to get into the university of
your choice?
PATIENT: Because my grades were really not so hot.
THERAPIST: Well, what was your grade average?
PATIENT: Well, pretty good up until the last semester in high school.
THERAPIST: What was your grade average in general?
PATIENT: A's and B's.
THERAPIST: Well, how many of each?
PATIENT: Well, I guess almost all of my grades were A's, but I got terrible grades
in my last semester.
THERAPIST: What were your grades then?
PATIENT: I got two A's and two B's,
THERAPIST: SO your grade average would seem to me to come to almost all A's, Why don't
you think you'll be able to get into the university?
PATIENT: Because of competition being so tough.
THERAPIST: Have you found out what the average grades are for admission to
the college?
PATIENT: Well, somebody told me that a B+ average should suffice.
THERAPIST: Isn't your average better than that?
PATIENT: I guess so.
(Becket aI., 1979)
NOTE: By learning to scrutinize and criticize her automatic thoughts and marshaling
evidence against them, the patient undermines her negative automatic
thoughts, and they wane.
REATTRIBUTION TRAINING
Depressed patients tend to blame themselves for bad events for which they are not, in fact, responsible. To counteract such irrational blame, the therapist and the patient review the events, applying the standards of non-depressed individuals in order to come up with an assignment of blame. The point here is not to absolve the patient of blame, but rather to let him see that there may be other factors besides his own incompetence that contribute to a bad event.
A fifty-one-year-old bank manager in a state of deep depression believed he was
ineffective in his job. His therapy session proceeded as follows:
PATIENT: I can't tell you how much of a mess I've made of things. I made another major error
in judgment which should cost me my job.
THERAPIST: Tell me what the error in judgment was.
PATIENT: I approved a loan which fell through completely. I made a very poor
decision.
THERAPIST: Can you recall the specifics about the decision?
PA TIENT: Yes. I remember it looked good on paper, good collateral, good credit
rating, but I should have known that there was going to be a problem.
THERAPIST: Did you have all the pertinent information at the time of your decision?
PATIENT: Not at the time, but I sure found out six weeks later. I'm paid to make
profitable decisions, not to give the bank's money away.
THERAPIST: I understand your position. But I'd like to review the information
which you had at the time your decision was required, not six weeks after the decision had been made.
~~~~~~~~
When the patient and the therapist reviewed this information, they concluded
that the patient had made his judgment on sound banking principles. He recalled
that he had even made an intensive check into the client's financial background,
which he had forgotten (Beck et aI., 1979).
Such reattribution training enables patients to find sources of blame other
than themselves, and it thereby raises their low self-esteem.
THE SEARCH FOR ALTERNATIVES
A fourth technique of cognitive therapy
attacks the patient's closed system in which all problems are seen as unsolvable.
Alternative solutions to the problems are explored and a course of action set.
A twenty-two-year-old graduate student had been given a C on his paper by his
English professor and was convinced that he was "a reject." The therapist offered
alternative interpretations for the C, other than this being proof that "he couldn't
make it in school." Each alternative was rated by the patient.
The rating simply consisted of proportions of 100 percent that would represent
the degree of "believability" of each explanation. The listing in decreasing order
of believability went as follows:
1. "I'm a reject who doesn't have any ability in English." 95%
2. "The grade was not very different from that of other students." 3%
3. "The professor provided the comments to help with future essays and therefore thinks I have some ability." 2%
Fortunately, the therapist convinced the patient to get some more information
before he withdrew from the course. He encouraged the patient to call his professor from his
office. On the telephone, the patient found out that (1) the average class grade was a C, and (2)
the professor thought that although the style of the essay was "wanting," the content was
"promising." The professor suggested that they have a further discussion to explain his
criticisms. As a result of this new information, the patient became more animated and cheerful.
Instead of viewing himself as a "reject," he readily agreed that he required concrete instruction
in writing style. He decided to get some tutoring and to complete the term rather than withdraw
from the course. (Adapted from Beck et al., 1979.)
The patient believed that getting a C meant he was incompetent. Alternative
explanations were not credible to him and he was prepared to act
based on his most catastrophic interpretation of the situation. Once alternatives
were furnished and the patient gained realistic information, both the
depressed mood and the self-destructive actions of the patient were reversed.
CHANGING DEPRESSOGENIC ASSUMPTIONS
The final technique of cognitive
therapy is the explicit change of depress genic assumptions (Ellis,
1962). Beck outlines six assumptions that depressed individuals base their
life upon, thereby predisposing themselves to sadness, despair, and disappointment:
(1) in order to be happy, I have to be successful in whatever I
undertake; (2) to be happy, I must be accepted by all people at all times; (3) if
I make a mistake, it means I am inept; (4) I can't live without love; (5) if
somebody disagrees with me, it means he doesn't like me; and (6) my value
as a person depends on what others think of me. When the patient and therapist
identify one of these assumptions, it is vigorously attacked. The validity
of the assumption is examined, counterarguments are marshaled,
plausible alternative assumptions are presented, and the disastrous consequences of holding the
assumptions are exposed.
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Treating:
Depression and Suicide
Post-Traumatic Stress Disorder (PTSD)
Social Anxiety
Generalized Anxiety
Panic Disorder
Major Depression Disorder
Agoraphobia
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For the Therapy I recommend click here:
The Liberator Method