CO GN IT I V E B E H A V IO R A L

T RE A T M E N T O F
MAJOR D E P R E S S I O N
BY :
SABA RIAZ

CLIN IC AL P SYCHO L OGIST

WHAT IS COGNITIVE-BEHAVIORAL
THERAPY (CBT)?
• A PROBLEM-ORIENTED THERAPY
• FOCUS ON PRESENT AND FUTURE
• SHORT-TERM FORMAT
• SESSIONS ARE STRUCTURED
• INVOLVES A STRONG WORKING ALLIANCE
• HOMEWORK IS A CENTRAL FEATURE
• BASED ON COGNITIVE THEORY
• REQUIRES COLLABORATIVE EMPIRICISM
EFFECTIVENESS OF CBT FOR DEPRESSION

• CBT HAS BECOME ONE OF THE MOST OFTEN PRACTICED TREATMENTS FOR
DEPRESSION AND IT HAS BEEN FOUND TO BE AN EFFECTIVE TREATMENT OF
DEPRESSION IN MOST EFFICACY STUDIES.

• IT AIMS TO ALLEVIATE DEPRESSION THROUGH THE DIRECT MODIFICATION OF

THE CLIENTS' IRRATIONAL AND NEGATIVE BELIEFS.
CORE SYMPTOMS OF DEPRESSION
• Sad or low mood for greater than two weeks
or
• Loss of interest or pleasure for greater than two weeks
+
• appetite/weight changes
• sleep problems
• agitation or retardation
• fatigue
• worthlessness/guilt
• concentration difficulties
• thoughts of dying
Treatment options
THEORY OF DEPRESSION
COGNITIVE MODEL
BECK’S NEGATIVE COGNITIVE TRIAD

Others/World Future
“I hate living here” “Things will get worse”
NEGATIVE THOUGHTS ABOUT SELF

 “I must be worthless for all of these awful

things to have happened to me.”
 “If I were a good person, I wouldn’t have been abused.”

 The core belief underlying each of these thoughts is worthlessness.

 Such thoughts can have a detrimental impact by contributing to low
self-esteem, low self-confidence, interpersonal relationship
problems, and interfering with willingness to actively become
better.
NEGATIVE THOUGHTS ABOUT THE WORLD

 Negative thinking about the world is a pattern of thinking in

which an individual tends to notice and recall negative aspects
of experiences more readily than positive or neutral events.
NEGATIVE THOUGHTS ABOUT THE FUTURE
“Nobody will like me.”
 “I won’t be good at it.”
 “What’s the use in trying? I’ll never get any better.”

 When depressed, individuals typically imagine the future

as being completely negative. This anticipation of events
turning out negatively is called hopelessness.
 e.g. rejection
Early experience and criticism
from parents
Negative core I am incompetent
beliefs/schemas

Negative life event

Activation of
Nothing ever goes right for me
schema

Negative automatic
thoughts

Depression
THE “C” IN CBT

 CT emphasizes techniques designed to help people detect,

evaluate, and modify their inner thoughts, particularly those
associated with emotional symptoms such as depression,
anxiety, and anger.
EMOTIONS
Identifying Emotions
• Generally one descriptive word.
• Noticing body changes (e.g. tension or heaviness) might signal a
mood.
• Try to identify 3 different moods in a day.
• Pick a mood and identify a situation where you felt each mood.
• Important to distinguish from thoughts.
THE “B” IN CBT

Depression: Behavioral Activation

• Monitoring daily activities
• Assessment of pleasure and mastery
• Graded task assignments
• Cognitive rehearsal and problem solving around tasks
• Social skills (assertion, communication)
THE “B” IN CBT
 Actions are connected to the way we feel.
 When a client tracks feelings of depression they may discover
that when they are depressed they are:
 more passive;
 less active; and
 often stop pleasurable activities
 As an initial step toward treating depression, it can be very
helpful to increase activities – especially pleasurable activities
or activities that create a sense of accomplishment.
THE “B” IN CBT
 By tracking activities, we can discover how they affect our
mood.
 By scheduling and completing activities that are enjoyable or
create a sense of accomplishment, your client will be making
behavioral changes that can lead to improved mood.
 Activity scheduling allows you to measure how much your
client feels a sense of pleasure and/or accomplishment from
the activities they partake in.
THE “B” IN CBT
 Activity Scheduling -
 Focuses on activity assessment and increasing mastery and
pleasure.
 Since depressed clients tend to underreport positive experiences
and emphasize negative experiences, self-reports may not be as
accurate as a log of weekly activities.
 Clients are encouraged to document the actual activities they
engaged in and the amount of time spent doing each activity.
THE “B” IN CBT: BEHAVIORAL ACTIVATION

 Activity Scheduling -
 Using a scale, such as 0-10, clients are asked to rate mastery
and pleasure of each activity, where 0 suggests there was no
experience of accomplishment or pleasure and 10 indicates a
great sense of accomplishment or pleasure for the activity.
THE “B” IN CBT: BEHAVIORAL ACTIVATION

 Activity Scheduling -
 If there is a lack of experiences of mastery or pleasure in your
client’s day-to-day life, you can schedule activities that will
make him or her feel better about themselves.
 Generate a list of activities high in pleasure and mastery.
Evaluate negative automatic thoughts that may interfere with
client’s ability to follow the activity schedule as planned. And
assign the new schedule for the upcoming week.
THE “B” IN CBT: BEHAVIORAL ACTIVATION
 Examples of Pleasurable Activities:
 Listening to music
 Drawing/painting
 Yoga/meditation
 Going to a sporting event
 Going to a restaurant
 Visiting/telephoning a friend
THE “B” IN CBT: BEHAVIORAL ACTIVATION
EXERCISE:

First,
choose a mood that is troublesome for you.
MOOD: _______________________

During this week, you will be rating this mood on a 0-100 point
scale.
1----------20---------------50--------------80--------100
Not A little Medium A lot Most I’ve
at all ever felt
THE “B” IN CBT: BEHAVIORAL ACTIVATION
Example Activity Schedule
Time MON TUES WEDS THURS
6-7 AM Wake Up (60) Wake Up (60) Wake Up (60) Wake Up (60)

7-8 AM Walk, breakfast Lie in bed (80) Breakfast (40) Shower, dress (50)
(40)
8-9 AM Golf (40) Dress (80) Walk (30) Walk (40)
9-10 AM Golf (40) Breakfast (80) Phone call (Bob) Shopping (30)
(30-60)
2-3 PM Shopping with Wash dishes (80) Walk (20) Play cards (20)
Sylvie (40)
8-9 PM TV (60) Movie (50) Play cards (20) Drive home (10)
THE “B” IN CBT: BEHAVIORAL ACTIVATION

 Learning from the Activity Schedule:

1. Did my mood change during the week? How? What patterns do I

notice?
2. Did my activities affect my mood? If so, how?
3. What activities helped me feel better? Why? Are these activities in
my best long-term interest?
4. What other activities could I do that might also make me feel better?
THE “B” IN CBT: BEHAVIORAL ACTIVATION

5. What activities helped me feel worse? Why? Are these

activities in my best interest to do?
6. Were there certain times of the day (e.g., mornings) or week
(e.g., weekends) when I felt worse?
7. Can I think of anything I could do to feel better during these
times?
THE “B” IN CBT: BEHAVIORAL ACTIVATION

 Were there certain times of the day or week when I felt

better?
 What activities can I plan in the coming week to increase the
chances that I will feel better this week? Over the next few
months?
THE “B” IN CBT: BEHAVIORAL ACTIVATION

 Another common behavioral technique is graded task assignment.

To help clients initiate activities for mastery and pleasure,
activities can be broken down into smaller, more manageable
steps, and are accomplished one at a time.
 The client is encouraged to list the behaviors that he or she used
to engage in prior to becoming depressed. They then assign
these activities to themselves beginning with the least threatening
changes and progressing to the most difficult behaviors.
THE “B” IN CBT: BEHAVIORAL ACTIVATION

 Cognitive Rehearsal & Problem-Solving -

 Depression tends to impair problem-solving ability. Depressed
individuals often struggle to find good solutions to problems and
express low confidence in their solutions.
 Sometimes individuals with depression have never learned problem-
solving skills, or have developed poor strategies for solving problems.
 Deficits in problem-solving ability may impair one’s ability to cope
with stressors related to depression.
THE “B” IN CBT: BEHAVIORAL ACTIVATION

Problem Solving Steps…

1. Define the problem
2. Generate range of solutions
3. Evaluate and decide on solution
4. Implement and evaluate solution
THE “B” IN CBT: BEHAVIORAL ACTIVATION
 Assertiveness Training -
 Techniques such as assertiveness training are used to target
behavioral symptoms of depression.
 An assertive person is one who acts in his/her own best
interests, stands up for self, expresses feelings honestly, is in
charge of self in interpersonal relations, and chooses for self.
 Assertive behavior is positive and will bring results in one’s
dealings with others. Not being assertive is one way to
cultivate low confidence, self esteem, and worse.
THE “B” IN CBT: BEHAVIORAL ACTIVATION

Assertiveness training can assist clients in:

 1. expressing themselves in a balanced manner;
 2. standing up for their rights;
 3. making decisions more easily;
 4. being more able to refuse requests;
 5. giving and receiving compliments; and
 6. expressing anger more constructively.
THE “C” IN CBT
 Therapist helps clients recognize and change
pathological thinking at two levels of information
processing: automatic thoughts and schemas.
Automatic Thoughts –
 Cognitions that stream rapidly through our minds when we are in
the midst of a situation or recalling events.
Schemas –
 Core beliefs that act as a template or underlying rule for assessing
information.
THE “C” IN CBT

Automatic Thoughts:
• These “pop” into one’s head, and usually not even aware of
them; however, we can learn to bring these thoughts into
consciousness.
• These thoughts can become predictable when underlying
beliefs are identified.
THE “C” IN CBT
• They can be words (e.g., “I’ll be fired”), images or mental
pictures (e.g., “seen” herself as a homeless person pushing a
shopping cart down the street), or memories (e.g., the
memory of being hit on the hand with a ruler by her fifth-
grade teacher when she made a mistake).
• One of the most important clues that automatic thoughts
might be occurring is the presence of strong emotions (“hot
thoughts”).
– Clients are often more aware of the emotion they feel as a result
of the thought than of the thought itself.
THE “C” IN CBT
 Toidentify automatic thoughts, clients are asked to notice what
goes through their mind when they have a strong feeling or
reaction to something.

– What was going through my mind just before I started to feel this
way?
– What does this say about me if it is true?
– What does this mean about me, my life, my future?
– What am I afraid might happen?
THE “C” IN CBT
– What is the worst thing that could happen if it is true?
– What does this mean about how the other person(s)
feel(s)/think(s) about me?
– What does this mean about the other person(s) or people in
general?
– What images or memories do I have in this situation?
THE “C” IN CBT

 Cognitive Restructuring -
 A large portion of treatment in CBT is dedicated to working
with automatic thoughts. This is typically done in two phases:
 1) identifying automatic thoughts; and
 2) modifying negative automatic thoughts.
THE “C” IN CBT
Cognitive Errors: These are inaccurate or irrational automatic
thoughts.

All-or-Nothing Thinking: Judgments about oneself, personal

experiences, or other are all good or all bad, a total success or a total
failure, completely perfect or completely flawed.

–One condemns themselves based on a single negative comparison such as, "I lost
the game (i.e., tennis), therefore I'm a total loser in everything," or "I couldn't operate
the new piece of equipment therefore I'm completely useless".
THE “C” IN CBT

Overgeneralization: You see a single negative event as a never-

ending pattern that negative events will keep happening to you.

–In this type of thinking, the person usually makes negative predictions for the future
based on a single negative event such as, "He turned me down for a date; no one will
ever want to go out with me now," or "I can't tolerate running and playing soccer
with my son, therefore I'll never be able to be involved in his life."
THE “C” IN CBT
Mental Filter: A conclusion is drawn after looking at only
a small portion of the available information. Salient data is
ignored in order to confirm the person’s biased view of the
situation.

–For example: I didn’t get all of my work done today, I’ll never be
good at anything.
THE “C” IN CBT
Disqualifying the Positive: Ppositive experiences are rejected by
insisting they "don't count" for some reason or another. In this way, a
negative belief can be maintained.

–For example:
–A client completes tasks on the activity schedule and then decides it
was pathetic to set that task as a goal.
THE “C” IN CBT
Jumping to Conclusions: A negative interpretation is
made even though there are no definite facts to
convincingly support this conclusion.

–For example:
–“He said he has to leave, he must have thought our conversation was
so boring that he made up an excuse to leave.”
THE “C” IN CBT
Magnification/Minimization: The significance of an attribute,
event, or sensation is exaggerated or minimized.

For example:
“I can’t believe I made a mistake during that presentation, it ruined the entire
thing!”

“The fact that I met that deadline was nothing really, any idiot could have done
it”.
THE “C” IN CBT
Catastrophizing: Focus is on the most extreme negative
consequences of a given situation.

For example:
Getting called into the bosses office is interpreted as “I’m going to be
fired”
THE “C” IN CBT

Emotional Reasoning: What someone feels determines

what they think. It is assumed that negative emotions
reflect what the way things really are.

–For example:
–"I feel really sad therefore the world must be a miserable place”
THE “C” IN CBT

“Must,” “Should,” or “Never” Statements: These are

inflexible rules for behaviour that are learned, or are
expectations that one must live up to.
–For example:
–"I never do anything right," or "I should be better by now," or "I
should be able to handle this, and "I must be weak."
THE “C” IN CBT
Personalization: Excessive responsibility or blame is
taken for negative events.

–For example:
–“The family dinner was a disaster because I felt down so nobody was
able to enjoy themselves."
THE “C” IN CBT
 Schemas:
 The basic templates or rules for information-processing that
underlie the more superficial layer of automatic thoughts.
 These beliefs are also related to emotions and behaviors that
are maladaptive
 These start to take shape in childhood and are influenced by a
multitude of life experiences.
THE “C” IN CBT
–Core Beliefs
– Global and absolute rules for interpreting information related to self-esteem
– The deeper cognitive structures, which aren’t directly as observable as
automatic thoughts.
– Typically deduced rather than identified explicitly
– Drive both the intermediate beliefs and compensatory strategies
– Most difficult to change, and require devoted attention; global, rigid, and
over-generalized
– (e.g., “I’m unlovable”)
THE “C” IN CBT
THE “C” IN CBT

 Socratic Questioning -
 The style of questioning used in CBT to change dysfunctional
thinking.
 One of the more difficult aspects of CBT for practitioners to
master.
THE “C” IN CBT