WOMEN in RECOVERY – Depression, a Way Out!

Depression, a Way Out!

Many depressed people wonder Is depression something I can think my way out of, or is it a medical problem. Lets say you were hoping to land a big promotion and discovered you were passed over for someone 10 years younger. Or maybe you just got a Dear John or Dear Jane letter that came like a bolt out of the blue. Right now you might be feeling down, wanting to binge on chocolate chip cookies and sleep most of the day generally feeling like a worthless loser. In short, you’re depressed. The cause of your depression was being passed over for the job or being rejected, right? “Wrong!”, say practitioners of ‘cognitive behavioral therapy'[CBT].

Thinking differently The cause of your depression may be your own irrational and self-defeating thoughts, according to the principles of CBT. Cognitive simply refers to thoughts, ideas or the ability to process information. By the same token, the way to pull out of the depression is to change the way you think. If all this sounds hard to swallow, consider the way a threemonthold infant would react to seeing a loaded revolver waved in front of his face. Most likely he would be curious or indifferent or even amused by the strange object. Try the same thing with most adults, and you would probably find a very frightened individual. The difference lies not in the gun, but in the very different ways infants and adults think about guns. When people become clinically depressed, CBT theorists argue, theyre usually tormenting themselves with unproved, exaggerated, selfdeprecating thoughts. They may not be aware of them, but these thoughts fuel the depression, nevertheless. For example, the depressed individual may think, I got passed over for the job, so I must be a total flop in life. Ill never get a promotion now in fact, Ill probably never get anywhere in life This kind of exaggerated, allornothing thinking leads to the feeling we call depression. Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that addresses dysfunctional emotions, behaviors, and cognitions through a goal-oriented, systematic process. The name refers to behavior therapy, cognitive therapy, and to therapy based upon a combination of basic behavioral and cognitive research. CBT is effective for the treatment of a variety of conditions, including mood, anxiety, personality, eating, substance abuse, tic, and psychotic disorders. Many CBT treatment programs for specific disorders have been evaluated for efficacy; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments. CBT was primarily developed through an integration of behavior therapy (first popularized by Edward Thorndike) with cognitive therapy (developed by Aaron Beck and Albert Ellis). While rooted in rather different theories, these two traditions found common ground in focusing on the “here and now”, and on alleviating symptoms. The premise of cognitive behavioral therapy is that changing maladaptive thinking leads to change in affect and in behavior. Therapists or computer-based programs use CBT techniques to help individuals challenge their patterns and beliefs and replace “errors in thinking such as overgeneralizing, magnifying negatives, minimizing positives and catastrophizing” with “more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior”. CBT helps individuals replace “maladaptive … coping skills, cognitions, emotions and behaviors with more adaptive ones”, by challenging an individual’s way of thinking and the way that he/she reacts to certain habits or behaviors. CBT includes a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy and acceptance, and commitment therapy.

According to Gatchel et al. (2008), CBT has six phases: 1. Assessment 2. Reconceptualization 3. Skills acquisition 4. Skills consolidation and application training 5. Generalization and maintenance 6. Post-treatment assessment follow-up The reconceptualization phase makes up much of the “cognitive” portion of CBT. A summary of modern CBT approaches is given by Hofmann.

There are different protocols for delivering cognitive behavioral therapy, with important similarities among them. Use of the term CBT may refer to different interventions, including “self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting”. Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches. Cognitive behavioral therapy is most closely allied with the scientist–practitioner model, in which clinical practice and research is informed by a scientific perspective, clear operationalization of the problem, and an emphasis on measurement, including measuring changes in cognition and behavior and in the attainment of goals. These are often met through “homework” assignments in which the patient and the therapist work together to craft an assignment to complete before the next session. The completion of these assignments – which can be as simple as a person suffering from depression attending some kind of social event – indicates a dedication to treatment compliance and a desire to change. The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment. Effective cognitive behavioral therapy is dependent on a therapeutic alliance between the healthcare practitioner and the person seeking assistance. Unlike many other forms of psychotherapy, the patient is very involved in CBT. Whether you’re visiting a psychotherapist in the Toronto area or in London, the process of CBT means that you, as the patient, will be heavily involved with the treatment. For example, an anxious patient may be asked to talk to a stranger as a homework assignment, but if that is too difficult, he or she can work out an easier assignment first. The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure. Anxiety disorders CBT has been shown to be effective in the treatment of all anxiety disorders. A basic concept in some CBT treatments used in anxiety disorders is in vivo exposure, a term describing a technique where the patient is gradually exposed to the actual, feared stimulus. The treatment is based on the theory that the fear response has been classically conditioned, and that avoidance of it negatively reinforces and maintains the fear. This “two-factor” model is often credited to O. Hobart Mowrer.[42][page needed] Through exposure to the stimulus, this harmful conditioning can be “unlearned” (referred to as extinction and habituation). Schizophrenia, psychosis and mood disorders Cognitive behavioral therapy has been shown as an effective treatment for clinical depression. The American Psychiatric Association Practice Guidelines (April 2000) indicated that, among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder. One etiological theory of depression is Aaron T. Beck’s cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events, and the negative schema is activated later in life when the person encounters similar situations. Beck also described a negative cognitive triad, made up of the negative schemata and cognitive biases of the person, theorizing that depressed individuals make negative evaluations of themselves, the world, and the future. Depressed people, according to this theory, have views such as, “I never do a good job”, “It is impossible to have a good day”, and “things will never get better.” A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. This is the negative triad. Beck further proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, over-generalization, magnification, and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema. In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse, and managing relapses. Several meta-analyses have shown CBT to be effective in schizophrenia, and the American Psychiatric Association includes CBT in its schizophrenia guideline as an evidence-based treatment. There is also some (limited) evidence of effectiveness for CBT in bipolar disorder and severe depression. A 2010 meta-analysis found that no trial employing both blinding and psychological placebo has shown CBT to be effective in either schizophrenia or bipolar disorder, and that the effect size of CBT was small in major depressive disorder. They also found a lack of evidence to conclude that CBT was effective in preventing relapses in bipolar disorder. Evidence that severe depression is mitigated by CBT is also lacking, with anti-depressant medications still viewed as significantly more effective than CBT, although success with CBT for depression was observed beginning in the 1990s. Computer-based therapy Computerized Cognitive Behavioral Therapy (CCBT) has been described by NICE as a “generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet, or interactive voice response system”, instead of face-to-face with a human therapist. While it cannot replace face-to-face therapy, this can provide an option for patients, especially in light of prohibitive costs and lack of availability associated with retaining a human therapist. A relatively new avenue of research is the combination of artificial intelligence and CCBT. It has been proposed to use modern technology to create CCBT that simulates face-to-face therapy. This might be achieved in cognitive behaviour therapy for a specific disorders using the comprehensive domain knowledge of CBT. One area where this has been attempted, is the specific domain area of social anxiety in those who stutter. Randomized controlled trials have, however, proven the effectiveness of CCBT in treating depression and anxiety disorders, and in February 2006 NICE recommended that CCBT be made available for use within the NHS across England and Wales for patients presenting with mild-to-moderate depression, rather than immediately opting for antidepressant medication. The 2009 NICE guideline recognized that there are likely to be a number of computerized CBT products that are useful to patients. They have, however, removed their endorsement of any specific product. If you are interested in trying this kind of approach, please feel free to connect with Lisa Derencinovic B.A. B.S.W. M.S.W. R.S.W. at Counselling with Lisa Telephone: 416 821-7315