Cognitive – Depression

In this section:

  • Cognitive explanation of depression: Beck’s cognitive triad, negative schemas, magnification or minimization
  • Ellis’ ABC model
  • Cognitive treatments for depression: Becks Cognitive Behavioural Therapy (1989) Identify, educate & homework
  • Ellis’ Rational Emotive Behaviour Therapy (REBT) – identify, educate through logical, empirical and pragmatic disputing & homework
  • David et al (2008) effectiveness of REBT
  • Whitfield & Williams (2003) practical limitations of CBT

Beck’s cognitive triad

Essentially Beck believes that a depressed person has developed a negative set of schemas upon which their expectations about life are based.  For example they may have developed a self-blame schema which makes them feel responsible for all the things in their life that go wrong.

According to Beck there are three types of cognition: views, schemas and biases that interact and cause an individual to become depressed.

The Negative Triad
The triad involves unrealistically negative views about self, the world and the future. For example:

Negative views about the world: ‘Everyone is against me because I’m worthless’

Negative views about the future: ‘I’ll never be good at anything’

Negative views about oneself: ‘I’m worthless and inadequate’

Faulty Information Processing: Beck believed that these negative schemes meant that the individual would have a tendency to focus on the negatives in any situation. For example, you achieve an A in your Psychology but because you didn’t get an A* you believe that you are a failure (oneself), that you will never get an A* (future) and that no one wants you to succeed (world)

Ellis’s ABC

Ellis’s model focuses on how external events are ‘blamed’ for the unhappiness being experienced. Ellis believes that negative and irrational beliefs develop due to the connection people make to events and experience.

A. Activating Event
Ellis believed events in our lives were the trigger for depression.  Events such as losing a job, family break up, disappointments etc.

B. Beliefs

The belief or explanation about why the event occurred – typically irrational and negative. Some examples of irrational beliefs are:

1.Over-generalisation: When conclusions are drawn about one’s ability, performance or worth based on one single incident.

2.Personalisation: Attributing personal responsibility, including blame, for events over which a person has no control.

3.Musturbation: believing that they must be perfect and a tendency to set unachievable goals.

4.Magnification & Minimization: Involves exaggerating the negative and diminishing the importance of the positives.

C. Consequences

The feelings and behaviour the belief now causes – e.g. negative emotions, low mood, the symptoms of depression

Another example of the ABC model:

Activating event – exam failure

Beliefs – negative thoughts associated with the event – ‘I’m useless and stupid’.

Consequence – negative thoughts or behaviours that follow e.g. feeling upset, thinking about quitting 6th form.

Evaluation of Cognitive explanations for depression 

Strengths:

  • Supporting evidence for Beck – There is plenty of evidence to suggest that Beck’s views on negative thinking do apply to depressed people. Lewinson et al (2001) assessed teenagers with no existing history of depression and measured their level of negative thinking.  A year later those scoring highest for negative thinking were the ones most likely to be diagnosed with major depression.
  • Useful applications – The most powerful support for the cognitive explanation of depression is it has led to THE most successful treatments for depression. CBT in general have proved to be most effective in treating a variety of disorders including depression, eating disorders and anxiety disorders.
  • Freewill – This explanation believes that people can, to some extent, control their thinking. This can be seen as positive empowering approach to mental illness. It can help someone with depression who make lack control, realise that they have the power to take back control. This could arguably be more successful because it reinforces the idea that an individual can help themselves, rather than expect someone to treat the depression for you, which may not have long-term effects.

Weaknesses:

  • Cause and Effect – To some extent, the cognitive model always faces this issue.  Ellis and Beck both suggest that people with depression have faulty, negative or irrational thinking.  They assume that this thinking has caused the depression.  However, how do we know which came first, the depression or the thinking?  Is it possible that suffering from depression has caused the person to start thinking in a negative fashion? Lewinson (2001) may have just measured young people who had depression, but had not been diagnosed yet.
  • Generalisability issues – Some forms of depression such as bipolar also involve some loss of contact with reality such as hallucinations and delusions which again the cognitive model is unable to explain. In addition, Ellis’s theory is clearly better able to explain depression in relation to an activating event, but it doesn’t account for those who have depression that seems to have arisen from nowhere.
  • Alternative explanation – It can also be seen to be an over-simplification. Gottesman (2010)  found that the risk of mental illness was much greater for children who had of two parents with a diagnosis of bipolar (a form of depression) or schizophrenia: 27.3% of offspring with both parents diagnosed with schizophrenia, had developed schizophrenia or bipolar by the age of 52. The risk increased when the calculation included any other mental health issues – 67.5%. The cognitive model doesn’t consider the influence of genetics.  Similarly he places too great an emphasis on cognitive and doesn’t consider the role of factors such as relationships with others.
  • Freewill – Both Ellis and Beck seem to be placing some of the blame at the feet of the client. There is clearly more free-will in comparison to behaviourist and biological models.  People can, to some extent at least, control their thinking.  This is a mixed blessing.  It does suggest that people can be successfully treated.  The thinking can be changed.  However, it may also be interpreted as the patient being partially or totally to blame for the condition, and this could potentially

Cognitive Behaviour Therapy (CBT)

CBT is currently seen as being the most effective psychological method of treating depression.

The basic aim of CBT is ‘cognitive restructuring’. The therapist works with the patient to identify faulty/irrational beliefs and then tries to change them by challenging their beliefs and helping them to think about life in a different, more positive way. CBT takes time, there are usually about 20 sessions followed by ‘boosters’ in the first year to help prevent relapses.

Becks Cognitive Behavioural Therapy (1989)

Beck suggests the following aspects of CBT:

  1. The therapist works with the individual to identify negative schemas using Becks negative triad, this is also known as thought catching.
  2. The therapist then encourages the individual to act as a ‘scientist’. The patient is encouraged to challenge their negative thoughts by considering evidence for and against them.
  3. As part of the role as a ‘scientist’, the patient is set homework. They might be asked to record events that they enjoyed or incidents where people are nice to them. The therapist then uses this homework as evidence to disprove the negative thoughts when voiced in future sessions. This leads to cognitive restructuring – the individual replaces negative thinking with more rational and positive thoughts.
  4. The idea of this is to eventually get the patient to always be ‘the scientist’ and challenge negative, irrational beliefs about themselves, the world, the future (negative triad) without the therapist’s help.

Ellis – Rational Emotive (Behaviour) Therapy

The key aspects of Ellis’ REBT include:

  1. The therapist uses Ellis’ ABC model to identify irrational beliefs. For example: Activating event – exam failure, Beliefs – negative thoughts associated with the event – ‘I’m useless and stupid’.Consequence – negative thoughts or behaviours that follow e.g. feeling depressed.
  2. Ellis adds on a ‘D’ for his A,B,C model and this stands for DISPUTING. Ellis’ therapy focuses on challenging negative and irrational thoughts by disputing them. There are different types of dispute which can be used, including: 
  • Logical Disputing: the client is asked to question the basis for their illogical ideas; do they really make sense?
  • Empirical Disputing: how do their ideas match with the evidence; what empirical proof is there that their ideas are right? Is there any proof for your beliefs?
  • Pragmatic Disputing: emphasizes how damaging these ideas are to the person.  In what way is a believing that you are worthless useful?

The therapist is very directive and acts as a teacher. They use disputing to teach the individual to re-interpret the events in a more realistic light. This helps the individual to develop more rational beliefs and healthy coping strategies. Again, the role is to help the individual to dispute their irrational beliefs without the therapist, so that they become self sufficient.

What about the Behavioural part of CBT?

Behavioural activation is an approach that involves someone using behaviours to influence their emotional state. Therapists encourage the individual to be more active and participate in more enjoyable activities e.g. exercise, meet with friends etc.

This can make the individual feel good and makes them more likely to keep participating in those activities, therefore reinforcing positive behaviour, which in turn helps to encourage positive thinking.

Example of behavioural activation:

A person who usually loves gardening may struggle with motivation when they have a depressive episode. This may mean that they stop gardening entirely. However, if they are encourages to try and do a small amount of gardening each day, it proves that they can do it. This may improve their mood, keep them physically active, and remind them of things they value.

  • Ellis views the therapist as a teacher and does not think that a warm personal relationship with a client is essential. In contrast, Beck stresses the quality of the therapeutic relationship.
  • Ellis’ REBT is often highly directive, persuasive and confrontive. Beck places more emphasis on the client discovering misconceptions for themselves.

Evaluation of Cognitive Behavioural Therapies

Strengths:

  • Holistic – CBT tackles both the irrational/negative thoughts (cognition ) and the behavioural components such as seeking to encourage greater contact and interactions with others and seeking more pleasurable activities. Using both behaviourist and cognitive psychology is seen as offering a more effective treatment than either approach in isolation.  Similarly since it combines decades of mostly scientific research into two different approaches to psychology it is very securely grounded and well respected. However, it does ignore biology. As we can see from the March et al (2007) there was 86% of the patients had improved when participating in CBT and antidepressants.
  • Usefulness – CBT has been seen to be the most successful treatment for depression. CBT in general have proved to be most effective in treating a variety of disorders including depression, eating disorders and anxiety disorders. March et al. (2007) found that CBT was as effective as antidepressants, in treating depression. The researchers examined 327 adolescents with a diagnosis of depression and looked at the effectiveness of CBT, antidepressants and a combination of CBT plus antidepressants. After 36 weeks, 81% of the antidepressant group and 81% of the CBT group had significantly improved, demonstrating the effectiveness of CBT in treating depression. However, 86% of the CBT plus antidepressant group had significantly improved, suggesting that a combination of both treatments may be more effective. This study could also be used to highlight how CBT doesn’t work for everyone too. 
  • Freewill – CBT focuses on the idea that the individual has the capacity to control their thinking. This can be seen as positive empowering approach to mental illness. It can help someone with depression who make lack control, realise that they have the power to take back control. This could arguably be more successful because it reinforces the idea that an individual can help themselves, rather than expect someone to treat the depression for you, which may not have long-term effects.
  • Usefulness – CBT has been found to have long term effects when treating individuals with depression. David et al (2008) Using 170 patients suffering from major depressive disorder that were treated using REBT had better outcomes than those treated with anti-depressants 6 months after treatment. This makes the treatment more useful because it ensures that the individual does not need to return to be treated again. It also helps the individual to feel that they have been treated/cured. When taking medication, dosages are often changed or increased. An individual who is taking medication for depression, may never come off the medication. However, this can lead to a vicious cycle, where individuals stop taking drugs because they feel better, and then need to start taking them again when their symptoms come back.

Weaknesses:

  • Ignores Situational factors – Some have argued that CBT over emphasises the importance of cognitive processes.  Perhaps for example people’s negative emotions are not maladaptive but simply realistic interpretations of their situation. Some people may have negative thoughts, but it does not necessarily lead to depression. This may limit the validity and effectiveness of CBT when treating depression.
  • Individual differences – CBT might not be suitable for everyone.  It does require a certain level of intelligence and an ability to be introspective as well as to be able to communicate your thoughts adequately. Particularly with depression, the individuals feel extremely unmotivated and have very low self-esteem. This may mean that in serious cases of depression, CBT alone may not be effective. Suicide is very common in depression, and attending CBT sessions on a weekly basis is not a quick enough method to support someone at this stage of depression. Therefore, a combination of drugs and CBT, may be more effective in these cases.
  • Applications – One of the biggest issues with CBT is the cost, particularly in the UK where health care is delivered by the NHS at the taxpayer’s expense.  Whitfield and Williams (2003) found evidence that the NHS was struggling to provide CBT on a weekly basis to the many patients that would clearly benefit from the procedure.
  • Alternative treatments- CBT may not target all causes of depression.  It concentrates on behaviour and how individuals interpret the environment. It focuses on maladaptive and irrational thinking but does not consider biological issues such as genetics or brain chemistry which have been shown to play a crucial role in some forms of psychopathology.  For example, Gottesman (2010) found that the risk of mental illness was much greater for children who had of two parents with a diagnosis of bipolar or schizophrenia: 67.5%of offspring who had both parents diagnosed with schizophrenia, had developed a mental health issue by the age of 52.