Cognitive Behavioral Therapy for Depression

This section will look at cognitive behavioral therapy (CBT) and two related forms of CBT known as Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy (ACT).

Modern CBT was developed independently by two separate people: Aaron Beck, a psychiatrist, and Albert Ellis, a clinical psychologist. Both Beck and Ellis began working on their versions of the therapy in and around the late 1950s and early 60s. Both versions of the therapy are founded on the single basic idea that cognition, in the form of thoughts and preconceived judgments, comes before and determines people's emotional responses. In other words, what people think about an event that has happened determines how they will feel about that event. Depression happens because people develop a habit to view situations and circumstances in negative and biased ways. This leads them to constantly experience negative feelings and emotions as a result.

More specifically, cognitive behavioral therapists suggest that depression is caused by a combination of an unhelpful dysfunctional thought process and by maladaptive behaviors motivated by that thought process. Because these thoughts and behaviors are learned, people with depression can also learn new, more adaptive skills that raise their mood and increase their ability to cope with daily hassles and stressors. Another basic idea behind CBT is that if a person changes their thoughts and behavior, a positive change in mood will follow.

The cognitive aspect of CBT involves learning to identify distorted patterns of thinking and forming judgments. These thought patterns are also known as negative or maladaptive schemas, or core beliefs. Core beliefs are central assumptions people have made that influence how they view the world and themselves. People get so used to thinking in these core ways that they stop noticing them or questioning them. Simply put, core beliefs are the unquestioned background themes that rule a person with depression's perceptions. For example, a person with depression might think "I am unlovable" or "I am inadequate and worthless." Because these beliefs are not questioned, they are acted upon as though they are real and true.

Core beliefs serve as a filter through which people see the world. Core beliefs influence the development of "intermediate beliefs", which are related attitudes, rules and assumptions that follow from core beliefs. When people with depression have core beliefs that are negative and unrealistic, these lead people to experience mostly negative and unrealistic thoughts. Following along with the example started above, our person with depression might develop the attitude that, "It's terrible to be unloved". The intermediate belief might include the following rule, "I must please everyone" and an assumption to the effect that, "If I please everyone then people will love me."

Intermediate beliefs can influence people's view of a particular situation by creating "automatic thoughts." These are the actual thoughts or images that people experience flitting through their minds. Automatic thoughts are thoughts which occur in response to a particular situation. They are spontaneous, rather than the result of thinking through a situation or the logical reasoning that happens when someone concentrates.

Automatic thoughts happen effortlessly, more or less all the time. Most of the time we are unaware that they are happening. This is not because they are unconscious sorts of things but instead because we're so used to them that we don't notice them anymore. Automatic thoughts influence emotions and behaviors and can cause bodily responses. To continue the above example, if a friend of our person with depression does not return a phone call, our person with depression might think, "He's not calling me back because he hates me". It may never occur to her to create a different and less irrational explanations for the lack of a callback such as "he must be really busy today." Because the automatic thought "he hates me" is not challenged, our person with depression starts feeling hated, and then depressed.

Though every patient's automatic thoughts are unique, there are also clear patterns of depressive automatic thoughts that are common across many the minds of people with depression. Some common patterns of negative and irrational automatic thoughts include:

• Catastrophizing - always anticipating the worst possible outcome to happen. For example, someone expecting to be criticized or fired when the boss calls.
• Filtering - exaggerating the negative and minimizing the positive aspects of an experience.  For example, a person focuses on all the extra work that went into a promotion rather than on how nice it is to have the promotion.
• Personalizing - automatically accepting blame when something bad happens even when you had nothing to do with the cause of the negative event. For example, the person thinks "He didn't return my phone call because I am a terrible friend or a boring person. I caused him to not call."
• (Over) Generalizing - viewing isolated troubling events as evidence that all following events will become troubled. In this situation, a person might think that having one bad day means that the entire week is ruined.
• Polarizing - viewing situations in black or white (all bad or all good) terms rather than looking for the shades of gray. For example, "I missed two questions on my exam, therefore I am stupid", instead of "I need to study harder next time, but hey - I did pretty good anyway!"
• Emotionalizing - allowing feelings about an event to override logical thoughts of the events that occurred during the event. A person might think, "I feel so stupid that it's obvious that I'm a stupid person."

Dysfunctional beliefs are thinking habits that people learn. They are irrational and not based on reality. They are not objective, unbiased observation. Because such beliefs are not linked to reality very well, they tend to appear rather distorted when compared with reality. Dysfunctional beliefs are all people typically have to help them make sense out of the events that happen to them. Snap judgments are made (called Cognitive Appraisals) based on the assumptions present within dysfunctional beliefs. These judgments end up being biased and irrational. People look to their appraisals of stressful situations to know how to react. When they do, they see that situations look simply awful and worse than it really would appear if some reality testing were to happen. They react to that false or exaggerated sense of awfulness, and then experience depressive symptoms.