Balochistan Institute of Psychiatry and Behavior Science

Cognitive behavioral therapy for depression an introduction

Objectives:
Develop a shared formulation of depression with client.
Elicit negative automatic thoughts with a client.
Use the downward arrow technique to explore core beliefs.
Apply cognitive and behavioral intervention in the treatment of depression.
Know where to locate further reading and information regarding CBT for depression.

What is depression?
Depression is a common mental disorder present with depressed mood, sadness, anxious
or empty feelings, Feeling of hopelessness and/ or pessimism
Feelings of guilt, worthlessness and/ or helplessness, Irritability, restlessness
Loss of interest in activities or hobbies once pleasurable, including sex
Fatigue and decreased energy, Difficulty concentrating (poor concentration),
remembering details and making decisions

Types of Depression:
Depressive disorder: Recurrence of long episodes of low mood, one extended episode
that seems to be never ending.
 Atypical depression
 Post partum depression
 Catatonic depression
 Sexual affective disorder
 Melancholic depression

What is depression – continued?

Insomnia, early – morning wakefulness, or excessive sleeping, Overeating, or loss of
appetite, thoughts of suicide, suicide attempts, Persistent aches or pains, headaches,
cramps or digestive problems that do not ease even with treatment.

Evidence base
NICE guidelines – mild vs moderate, NIMH – By teaching new ways of thinking and
behaving CBT helps people change negative styles of thing and behaving that may
contribute to their depression.
NIMH also recommends IPT, NIMH suggests that for mild to moderate depression
psychotherapy may be the best treatment option.

DR WAHEEDULLAH PSYCHIATRIST 1
Balochistan Institute of Psychiatry and Behavior Science

Cognitive Model of Depression

Early experiences

Core beliefs

Underlying assumption

Critical incident

Activate assumptions

Thoughts

Feeling Behavior

Physical

 Early experiences lead people to develop core beliefs

 From core beliefs unhelpful assumptions are generated that organize perception and
govern behavior
 Critical incident triggers the assumption
 Leading to negative automatic thoughts (NAT,S) which have knock on effect to mood
behavior and physiology

Five areas of CBT

DR WAHEEDULLAH PSYCHIATRIST 2
Balochistan Institute of Psychiatry and Behavior Science

Maintaining Factors

Early experiences

Core beliefs

Underlying assumption

Critical incident

Activate assumptions

Thoughts

Feeling Behavior

Physical

First Sessions
 Socialize to the model
 Previous experience of therapy and expectations
 Contracting
 Assessment
 Problem list
 Goal setting
 Agenda setting

Goal Setting
 Specific
 Measurable
 Realistic
 Time limited

DR WAHEEDULLAH PSYCHIATRIST 3
Balochistan Institute of Psychiatry and Behavior Science

Be Goal SMART
 I want more friends
 I want to stop worrying
 To stop thinking negatively about everything

What if the client can’t think of a goal?

 Magic/ miracle question (solution focused therapy)
 If I had a magic wand and I could use that wand to change everything for you over
night so that everything was better for you what would be the first thing that you
would notice in the morning that would tell you thing had changed?
 Helps client to start to think of life without the problem

Scaling question
 Asking client to rate on a scale the worst they have ever been
 The best they have ever been
 Where they would like to be on that scale
 What is realistic

Eliciting Negative Automatic Thoughts (Hot Thoughts)

 Aim is to encourage the client to notice what is going through their mind when they
have a strong reaction to a situation
 Link this thought to an emotion and rate the emotion
 Thought is an interpretation of the situation and it is this though that governs the
emotional response
 The thought with the highest emotional rating is the hot thought (NAT)

Downward Arrow Technique

 Technique to identify underlying assumptions and core beliefs that drive the NAT ‘s
 Explore what the NAT means to individual
 Can also ask the client to complete the following statements:
 I am
 Other are
 The world is

Downward arrow
 I am going to be rejected again
 (If that were true what would that mean)
 I‘ll never have close relationship
 If I get close to people I get hurt
 I need to protect myself

DR WAHEEDULLAH PSYCHIATRIST 4
Balochistan Institute of Psychiatry and Behavior Science

Case study ‒ Diana

 50 Year old woman
 Married (Second marriage)
 Five children (three at home)
 Previous CBT for depression with Graduate Mental Health Worker
 Reported that she found this helpful but wants additional sessions as depression has
returned

Background
 Was adamant that she wanted explore her childhood to help explain her current
problems
 Didn`t think she could improve long term without this
 Had liked CBT Previously hence referral currently
 Not on medication for depression at that point

Current situation
 Working as a support teacher for children with learning disabilities
 Living with three of her children and disabled husband
 Sixteen year old son with severe autism and behavioral difficulties
 Poor physical health Reported difficult relationship with husband
 Past suicidal ideation and some during the session but on plan

Problem list
 Recurrent relapse of depression
 Not happy at work
 Feels ‘walked all over , by family and colleagues
 Feels like she is taken for granted by friend and family

SMART Goals for Diana

 To voice disagreements in a meeting at work and reduce worry about this from an 8
to a 3
 To spend thirty Minutes a day doing something that she wanted to do (listening to
music reading)
 To identify trigger to low mood and keep mood above a ‘4’ for 80% of the time
 To understand the origins of recurrent low mood and like to current difficulties

DR WAHEEDULLAH PSYCHIATRIST 5
Balochistan Institute of Psychiatry and Behavior Science

Early experiences
 Impoverished area
 Never finished school ‒ left school early to take care of mentally ill relative
 Father had diagnosis of schizophrenia and was physically violent to Diana ‘ mother
 Diana observed physical violence but was never physical abused herself

Formulation for Diana

Early experiences
Observe physical violence

Core beliefs
I need to keep quiet

Underlying assumption
If I speak up I will make the situation
worse

Critical incident (s)

Activate assumptions

Thoughts
I can’t get my point across
No one like me/listens to me I
can’t say anything

Feeling Behavior
Anxious Depressed Upset Keep quite Leave the room
Avoid People at work

Physical
Nauseous Heart racing

Intervention
1. Behavioral activation
2. Monitor activities thought a daily diary
3. Rate each activity out of 10 for pleasure and mastery (sense of achievement)
4. Rate level of depression
5. Schedule activities based on information form the diary

DR WAHEEDULLAH PSYCHIATRIST 6
Balochistan Institute of Psychiatry and Behavior Science

Interventions Continued
1. Thought Challenging
2. Use thoughts identified on thoughts record and rate how much believe the thought
3. List all evidence that support the thought
4. List all evidence that support the thought is not true 100% of the time
4. Based on the evidence re ‒ rate how much you believe the original thought and re‒rate
emotion

Interventions Continued
A. Behavioral experiments
B. Identify belief to be tested
C. Rate conviction in this belief
D. Design experiment
E. Identify any problems with experiment and ways to overcome it
F. Record expected out come
G. Usually do experiment as homework but can be done in session
H. Record actual outcome
I. Create alternative belief based on new evidence

Interventions used with Diana

Behavioral experiment ‒ when disagree in a meeting speak out and observe what happens
Prediction that people would not speak to her following that (rate this belief)
Observed that people spoke to her just as much after the meeting (re ‒ rate belief and
create new belief based on this evidence)
Also found that people appreciated her input (further evidence)
Survey
Asked children how they knew she loved them and how does her know they love her

Interventions used continued

A. Consideration of evidence ‒ judge and jury
B. Rather than instantly believing NAT ‒considered evidence for and against the thought
C. Presented this as from perspective of prosecution and defense
D. Final decision up to the judge (Diana)
E. Decision to accept the thought or throw it out of court (Diana)
F. Decision to accept the thought or throw it out of court
G. Relaxation

Sue ‒case study

Using information sheet try to develop a formulation for Sue (in pairs)
Consider her early experiences and what beliefs these may have given rise to Sue ‒ case
beliefs and assumptions

DR WAHEEDULLAH PSYCHIATRIST 7
Balochistan Institute of Psychiatry and Behavior Science

Core Beliefs
1. I need the help of others
2. I am not good enough
3. Other people will always let me down

Assumptions
I. I need be perfect to be accepted
II. If I am not passive /accepting I will be rejected
III. I have to be careful or people will disappoint me

Possible interventions
In pairs think about what intervention could be developed with Sue

Interventions used
Tallying ‒ surveyed how often she told james she loved him (found it was very frequent)
Developed goal to reduce this and set up behavioral experiment
Behavioral experiment to reduce contact with parents
Role play to practice more assertive interaction with parents

Recommended Reading
Greenberger and padesky (1995) Mind over Mood
Fennell M.J.V (1989) Depression. In K.Hawton, P.M

Salkovkis, J. Kirk & D.M Clark (Eds) Cognitive behavior Therapy for Psychiatric
Problems: A practical guide.
Bennett ‒ Levy, j et al (2004) Oxford guide to behavioral experiment in Cognitive
therapy
Mood gym (http://moodgym.anu.edu.au
http://medschool.ucsf.edu/latino/manuals.spx#GroupDrop
CognitiveBahavisthorfatherapyoofhantimmofmajorDeree

DR WAHEEDULLAH PSYCHIATRIST 8