As this video takes a cognitive approach to explaining depression, it won't surprise you
that it is going to be suggesting that depression and behaviours associated with depression
are due to problems with internal mental processes.
So this means depressed people’s thinking is disturbed or put another way, their cognitions
are in some way broken or maladaptive.
You may remember cognitive psychologists use a term called a schema, a schema is a mental
framework built from experience, and we use them as mental shortcuts, they are a way of
quickly understanding the world and objects in the world, this means it doesn't take too
much mental energy do decide how to respond to a range of situations.
We have schemas for objects in the world, and a simple example I used in the cognitive
video was a schema for chair, we have a set of expectations about what a chair looks like
and what it can do, this means you don't need to make too much mental effort when interacting
with chairs in your everyday life, you will see a chair and just automatically sit on
it, scale that up to having a schema for everything in your life, and that's how we navigate the
world without excessive overthinking.
But these schemas, these automatic assumptions can lead to biases, and that's particularly
problematic when these biases are negative and are about ourselves and the events in
our lives.
Both of the following cognitive explanations in this video, Beck’s negative triad and
Ellis’s ABC model explain depression as due to faulty negative thinking, and also
suggest that the best way of treating depression is to challenge and change this negative bias.
[The cognitive triad - Beck] Aaron Beck argued people who are depressed
have three types of schema with an automatic negative bias; he called this the negative
triad.
These are negative beliefs people have about themselves, called self schemas, such as feeling
inadequate or unworthy.
They may also have negative schemas about the world, seeing it as hostile or threatening.
Finally, they may have negative schemas about the future, assuming that things will always
turn out badly.
These negative
schemas often develop in childhood but they provide the framework to persistent biases
in adulthood, leading us to perceive the world inaccurately, Beck calls these biases cognitive
distortions.
Some examples of cognitive distortions are, Overgeneralization, this is when an individual
has one negative experience and assumes that this will always happen.
So perhaps a student starts A levels, fails the first class test in one A level subject
and now they assume they will always fail on every future test in every subject.
Magnification and minimisation, also known as catastrophizing, magnification is when
people see a negative event as more important than it really is, and minimisation is perceiving
positive events as less important than they really are, so lets say in an interview the
individual gave one really silly response to a question, but for all of the other questions
they gave clear and competent answers.
Magnification would be focusing on that one mistake, and minimisation would be ignoring
all of the good responses.
A similar concept is selective abstraction, focusing on one detail out of context, this
involves a process of mental filtering, only focusing on the negative, say someone puts
up a post on social media, and they get lots of positive feedback, but they get one mean
comment, selective abstraction, also known as selective perception is mentally filtering
out all the positive comments, and focusing on just that one negative comment.
Absolutist thinking is when an individual classifies every experience into one of two
opposite, or dichotomous categories, brilliant or awful.
So the homework you completed for class has to be perfect in every detail or it's totally
rubbish, there is no okay or good enough.
When judging themselves people with depression select the extreme negative category.
These negative thought patterns can lead to negative behaviours, such as avoidance, withdrawal,
and inaction.
For example, an individual with depression may avoid social situations because they believe
that they will be rejected or ridiculed.
They may also withdraw from activities that they once enjoyed, such as hobbies or exercise,
because they believe that they are incapable of doing them well.
Finally, they may be unable to make decisions or take action because they believe that nothing
they do will make a difference.
[The ABC model - Ellis] ✅ Albert Ellis used something he called ABC
model to explain how someone with depression responds to stress, adversity and unpleasant
events in a way that leads to unhealthy emotions, The A in the abc model refers to the activating
event, this happens to people with and without depression, so it could be something major
like the end of a relationship, or as small as missing a bus.
The difference between someone with and without depression is B, their Belief, this could
be rational or irrational, a rational belief at the end of a relationship may be, we weren't
right for eachother, we wanted different things, I should move on.
An irrational belief maybe oh i'm fundamentally unlovable I will never be able to find someone
who will stay with me.
For the bus scenario, a rational belief may be ah, I was a little slow.
I will get the next one.
An irrational belief would be, the bus drivers hate me and dont want me to get home.
C is the consequence and you can see it would be different for each person depending on
if the belief is rational or irrational.
For the relationship scenario, someone with a rational belief would likely look for a
new healthy relationship, while the person with the irrational belief may either avoid
relationships altogether, or get into an unhealthy relationship, feeling they can't do better.
When it comes to missing the bus, a rational belief would lead to the consequence of waiting
for the next bus, an irrational belief may lead to walking home in the rain.
Ellis also uses an amusing sounding term that explains the source of irrational beliefs,
its mustabatory thinking, and it's a problem that comes from not accepting we don't live
in a perfect world, A quote from ellis is ““There are three musts that hold us back:
I must do well.
You must treat me well.
And the world must be easy.””, you can see those beliefs result in a lot of pressure,
and certainly we will be disappointed when we fail to achieve an unrealistic goal, other
people don't behave the way we want them to, or an unexpected event happens and ruins our
plans.
The cognitive approach to explaining depression: Evaluations
Grazioli and Terry (2000) assessed the thinking styles of 65 women before giving birth and
6 weeks after.
It was found that those women with negative thinking styles were the most likely to develop
postpartum depression, especially in women with infants who were identified as having
a difficult temperament.
This supports the idea that faulty thinking leads to depression, but also that there is
a diathesis-stress mechanism to Beck's theory, negative thinking is a vulnerability which
can be triggered by aversive life experiences like motherhood.
2 - ✅ Now, we have to be careful with this evaluation,
if your asked to outline and evaluate cognitive explanations for depression, that needs to
be our focus, not treatment.But it is true that the cognitive theories that explain depression
have led to highly effective cognitive therapies, March showed CBT had an effectiveness rate
of 81% after 36 weeks of treatment, the same as drug therapy.
So these treatments have been successful in helping people recover from depression, and
the fact that they are successful suggests the underlying cognitive explanations are
valid.
3 - However cognitive explanations are not full
explanations of depression, many people with depression also experience anger, and people
with bipolar depression experience manic phases, times when they feel extremely happy, overly
excited, confident and focused.
These features of some types of depression really can't be explained by theories like
Beck’s that explain depression as due to negative schemas, as schemas are resistant
to change.
4 - There is also significant evidence for a biological
origin of depression, family studies and genetic research suggests a predisposition to depression
is inherited, likely genes that influence the activity of neurochemicals like serotonin
in the brain.
And the effectiveness of drug treatments like SSRI’s, suggest there is a biological aspect
to depression.
5 -✅ Cognitive theories also depend on the assumption
that the person with depression’s thoughts are irrational, it could be that their lives
are objectively bad and depression is a reasonable response.
In fact some researchers think the bias is with the people without depression, they live
their lives with rose tinted glasses, selectively perceiving the world in a positive light,
giving ourselves overly positive self-evaluations and unrealistic optimism, the problem with
people with depression then is they have lost this positive bias, the rose tinted glasses,
and unfortunately, see the world how it really is.
https://doi.org/10.1037/0033-2909.103.2.193
The cognitive approach to treating depression: cognitive behaviour therapy (CBT), including
challenging irrational thought
1 General Rationale As the cognitive explanation for depression
is negative schemas leading to irrational thoughts, well it makes sense that the cognitive
strategy to treat depression is to change these schemas and challenge the irrational
thoughts.
There are two cognitive therapies, Beck’s CBT, and Ellis’s REBT.
2 Beck’s CBT
Beck’s CBT treats the “patient as a scientist” this means the patient generates and tests
hypotheses about the validity of their own irrational thoughts, the hope is when they
realise their thoughts don’t match reality this will change their schemas, and the irrational
thoughts can be discarded.
To go through this process clients are first taught how to gather data through thought
catching, this is identifying irrational thoughts coming from the negative triad of schemas.
To do this they are assigned a homework task of keeping a dairy, this is used to record
negative thoughts, but also identify situations that cause negative thinking.
Say for example someone may record when they were invited to a social event, the invitation
caused a range of negative thoughts related to the self, others and the future.
So, I’m so boring, I really don’t think I will have anything interesting to say, people
don’t tend to like me, I don’t think they will even talk to me and it's going to be
a really awkward experience and I’m not going to enjoy it.
The patient would be asked to attend this event, and importantly gather evidence by
recording what happens, this is hypothesis testing, comparing the negative thoughts to
what actually happens.
so maybe they did strike up a conversation with a group of people they didn’t know,
and actually found the event kind of fun.
To help raise the client's mood the therapist will also encourage behavioural activation,
this is taking part in activities that the sufferer used to enjoy so this may be team
sports, travelling or socialising with friends.
Ellis’s Rational emotive behavioural therapy is a development of his ABC model, adding
D for dispute and E for effect.
These disputes take the form of the therapist confronting the clients irrational beliefs
with empirical and logical arguments.
Empirical arguments challenge the client to provide evidence for their irrational beliefs,
while logical arguments attempt to show that the beliefs don't make sense.
In the relationship example the therapist would suggest it's not logical to think they
are fundamentally unlovable and will never be able to find someone who will stay with
them”, perhaps pointing to the fact that they managed to start a relationship to begin
with, so they will be able to do so again.
Empirically the therapist may point to the evidence of many relationships failing and
the individuals in those relationships going on to have new healthy relationships.
The E, of the model, the effect then is hopefully the reduction of irrational thoughts leading
to better consequences in the future.
REBT also includes what are known as shame attacking exercises, this is getting the client
to perform a behaviour they fear doing in front of others, so perhaps someone who thinks
they are a bad dancer, and hates the idea of dancing in public, will be asked to join
a dance class.
Performing these exercises shows the client they can act against their emotions and cope
with an unpleasant experience, that they can survive other people's disapproval, and actually
most people don't notice or care about our actions, and ultimately, we worry too much
about people's approval.
These explanations may have made it seem that Beck’s CBT and Ellis’s REBT are very similar,
and while they do have the same end goal, the cognitive restructuring of irrational
thoughts, how they get there is different, in Beck’s therapy the client is helped to
figure out the irrationality of their thoughts themselves, by acting as a scientist, while
for ellis the therapist explains the irrationality of the thoughts directly to the patient through
disputation.
The cognitive approach to treating depression: Evaluations
1 - March (2007) randomly assigned 327 patients
to one of three groups, CBT, drug therapy, in this study an SSRI called fluoxetine, and
the third group was given a combined treatment of CBT and drug therapy.
The results after 36 weeks supported the effectiveness of CBT, with an effectiveness rate that was
the same as drug therapy, both at 81%.
CBT also had a bigger reduction in suicidal events than drug treatment.
However the best results came from the combination treatment with an effectiveness rate of 86%,
and fewer suicidal events than either treatment alone.
DOI: 10.1001/archpsyc.64.10.1132 2 -
Potentially explaining the results of the above study is the fact that some people with
depression are too severely depressed to engage with CBT, completing homework, challenging
irrational thoughts and even attending sessions require motivation and commitment.
This means drug therapy may be required to stabilise a patient prior to psychological
therapy.
3 - The role of the patient in CBT is an active
one, the client is given the responsibility for the depression, and the therapist provides
the tools the client needs to address it.
There are different perspectives on this, supporters of CBT argue this gives the client
a sense of personal efficacy, a feeling that they are in control of directing their own
lives and have the power to make positive changes, better than the passive role of drugs
where the client is helpless without a biological intervention.
On the other side critics of CBT argue saying the client is responsible for the depression
can be seen as victim blaming, it’s suggesting the depression is all in the mind and would
go away if the client just thought differently, and this perspective could lead to clients
feeling more shame, and wider society thinking mental health conditions are less serious
than other medical conditions.
I will let you make your own decision on what side of that argument you want to come down
on.
4 - Another criticism is that both REBT and CBT
may be overly focused on the present and how to cognitively restructure how the client
thinks about their current situation.
Some clients do have serious trauma in their past that they may want to discuss with a
therapist, also reinterpreting present experience does not necessarily improve the present situation,
it may be that the client is in a unhealthy relationship, is experiencing unfulfilling
work, discrimination or has financial problems, concerns about these social problems are not
irrational, and may be a factor in the individuals depression.
Finally we can consider an economic argument for CBT, compared to drug therapy, CBT is
significantly more expensive for health services like the NHS to fund.
A course of CBT can take 16 to 20 one to one sessions with a trained therapist.
However many patents prefer CBT to drug treatments due to the lack of side effects and a belief
that CBT addresses the root cause of depression, it's not just reducing symptoms, and as the
CBT has been shown to be effective in the long term, this means once treated people
can return to work as a productive worker and continue contributing to the economy,
so from a cost benefit analysis many feel CBT is worth
the expense.