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CBT for Depression: Strategies and Techniques

Posted on October 11, 2019 at 7:00 PM

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We can broadly define CBT as a combination of cognitive and behavioural therapeutic approaches used to help clients modify limiting, maladaptive thoughts and behaviours, ones that are often inconsistent with consensual reality (Beck, Rush, Shaw, & Emery, 1979). The basic premise of CBT is that troublesome emotions are difficult to change directly, so CBT targets emotions by changing the thoughts and behaviours that are contributing to the distressing emotions.


Generally considered a short-term therapy, CBT often consists of about 8 to 12 sessions in which client and therapist work collaboratively to identify problem thoughts and behaviours. The therapist then uses the troublesome thoughts and behaviours to furnish the client with tools and techniques to alter the way they think, feel, and behave in a given situation. The CBT-generated skill set enables the individual to be aware of thoughts and emotions; to identify how situations, thoughts, and behaviours influence emotions; and to improve feelings by changing dysfunctional thoughts and behaviours.

 

Some have noted that “CBT” is an umbrella term and that there are a variety of CBT-based techniques used for different populations and different presenting issues; here we mainly refer to Albert Ellis’ Rational Emotive Behaviour Therapy (REBT) (Ellis, 1962) and Aaron Beck’s cognitive empiricism (Beck and Weishaar, 1995). The underlying principle of the therapy, however, remains the same: there is collaborative CBT skill acquisition and “homework” in between sessions (components which set CBT apart from typical “talk” therapies) (Schmied & Tully, 2009; Gasper, n.d.; Grazebrook, Garland & the Board of BABCP, 2005).

 

CBT strategies

 

CBT is based on the idea that the processing of information is crucial for the survival of any organism, but in various psychopathological conditions – such as anxiety disorders, mania, paranoid states, and of course depression – a systematic bias has been introduced into the client’s information-processing system, causing interpersonal problems and possibly even threatening survival, at least indirectly. Thus, the selective bias of depressed clients leads them into themes of loss and defeat.

 

The overall strategies of CBT are, first, collaborative empiricism between therapist and client to explore dysfunctional interpretations and try to modify them. Then guided discovery attempts to discover what threads run through the client’s misperceptions and beliefs; these are linked where possible to analogous experiences of the past, creating a rich tapestry telling the story of the client’s disorder.

 

As clients tune into the nature of the “program” causing their information-processing glitches, a cognitive shift may occur in which clients realise how the data admitted, and the manner of integrating them, determined the behaviour (usually neurotic) which then resulted. The shift involves installing a new program which is more adaptive. A person suffering from a depressive disorder, therefore, may realise that his or her program was causing selective attention to signals of loss, helplessness, defeat, and futility. Now, post-shift, attention can be turned to signals of hope and possibility, with the “program” for “defeat signals” being de-activated or at least turned down in “volume”. The shift to the neutral program (i.e., “there are some discouraging signals and some encouraging, hopeful signals”;) can be checked in the world. This feedback into the person’s system helps to reverse misinterpretations, catalysing readjustment (Beck & Weishaar, 1995).

 

CBT techniques, cognitive and behavioural

 

In CBT, verbal techniques are used to bring forth the client’s automatic thoughts, analyse the logic behind the thoughts, identify unhelpful assumptions, and examine the validity of the assumptions. Assumptions, once identified, are open to modification, which can occur by asking the client if the assumption seems reasonable, by having the client generate reasons for and against maintaining the assumption, and by presenting evidence contrary to the assumptions. Specific cognitive techniques include the following:

 

Decatastrophising: the “what-if” technique which helps clients prepare for feared consequences. This is helpful in decreasing avoidance.

 

Reattribution: a technique which tests automatic thoughts and assumptions by considering alternative causes of events. This particularly helps when clients perceive themselves as the cause of problem events.

 

Redefining helps clients mobilise when they believe problems are beyond personal control; these techniques may make problems more concrete, stating them in terms of the client’s own behaviour.

 

Decentring is used chiefly to help clients who erroneously believe that they are the focus of everyone’s (usually negative) attention.

 

Behavioural techniques are also used to modify automatic thoughts and assumptions. These employ behavioural experiments designed to challenge specific maladaptive beliefs and promote new learning. A client might, for example, (1) predict that a certain outcome will obtain, based on automatic thoughts, (2) carry out the agreed behaviour, and then (3) evaluate the evidence in light of the new experience. Some of the chief behavioural techniques used to foster cognitive change are:

 

Homework: opportunities to apply CBT principles between sessions. Assignments typically focus on self-monitoring, structuring time effectively, and implementing procedures for dealing with actual situations.

 

Hypothesis testing: with both cognitive and behavioural components; this technique must make the hypothesis both specific and concrete.

 

Exposure therapy: thoughts, images, bodily symptoms, and levels of tension are experienced by, say, an anxious client. Exposure to the anxiety triggers provides data for the client, who can examine specific thoughts and images for distortions.

 

Behavioural rehearsal and role-playing is used to practice skills or techniques which are later applied in real life. Role-playing may be taped in order to provide objective feedback with which to assess performance.

 

Diversion techniques: activities such as social contact, work, play, visual imagery, and physical activity are used to reduce strong emotions and decrease negative thinking.

 

Activity scheduling provides structure and encourages involvement. By rating, say, the degree of mastery and pleasure of an activity, depressed clients, for example, are able to see that they were not depressed at the same, unvarying level all day. They are able to contradict a belief that they cannot enjoy anything, and are further shown that activity takes some planning, so someone does not come to be an inert “couch potato” due to an inherent defect.

 

Graded task assignment: the client initiates an activity at a “safe” level and the therapist gradually increases the difficulty of assigned tasks (Beck & Weishaar, 1995).

 

Making it work in real life

 

Occasionally problems occur with clients misinterpreting – due to their automatic thoughts – what the therapist has said. Together, therapist and client can elicit these wrongly interpreted statements, looking for alternative interpretations – and if the therapist has made an error, of course, he or she accepts responsibility and corrects it (Beck & Weishaar, 1995). CBT has made invaluable contributions to the treatment of depression, but in some cases, clients will wish to work more deeply, to the root of their relational templates which engender invalid, unhelpful thoughts and assumptions. Other approaches, such as psychodynamic psychotherapy, can help with that.

References:

 

Beck, A.T. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Harper & Row.

Beck, A.T. & Weishaar, M.E. (1995). Cognitive Therapy. In Current Psychotherapies, 5th Ed., Corsini, & Wedding, Eds. Itasca, Illinois: F.E. Peacock Publishers, Inc.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Gasper, P. (n.d.) Assessment & formulation in CBT. The Marian Centre. Retrieved on 30 June, 2014, from: Website.

Grazebrook, K., Garland, A., & the Board of BABCP (British Association of Behavioural and Cognitive Psychotherapies). (2005). What are cognitive and/or behavioural psychotherapies? International Institute for Cognitive Therapy. Retrieved on 24 January, 2017, from: Website.

Schmied, V. & Tully, L. (2009). Effective strategies and interventions for adolescents in a child protection context: Literature review. Ashfield, NSW: Centre for Parenting & Research, NSW Department of Community Services. Retrieved on 24 June, 2014, from: Website.


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