Cognitive Treatments 4.1.4 Psychopathology The cognitive approach to treating depression: cognitive behavioural therapy including challenging irrational thoughts

Cognitive Behaviour Therapy (CBT) CBT is the most commonly used psychological treatment for depression, as well as other mental health problems (e.g. anxiety, panic, phobias, stress, bulimia, OCD, Post-Traumatic Stress Disorder, bipolar disorder, etc.) This is a method for treating mental disorders based on both behavioural and cognitive techniques The therapist aims to make the client aware of the relationship between thought, emotion and actions CBT can help people to change how they think (‘cognitive') and what they do (‘behaviour'). These changes can help them to feel better.

What is CBT? It is a way of talking (psychotherapy) about: how you think about yourself, the world and other people how what you do affects your thoughts and feelings. From the cognitive point of view therapy aims to deal with the thinking, such as challenging negative thoughts The therapy also includes behavioural techniques such as behavioural activation (encouraging patients to engage in those activities they are avoiding)

What is CBT? CBT can help to break the vicious circle of maladaptive thinking, feelings and behaviour. It focuses on the 'here and now' problems and difficulties. Instead of focusing on the causes of distress or symptoms in the past, it looks for ways to improve the state of mind now. When the parts of the sequence are clearly outlined and understood, they can be changed. CBT aims to get the person to a point where they can ‘DIY', and work out their own ways of tackling their problems.  

Each session will last between 30 and 60 minutes. What does CBT involve? The Sessions Meet with a therapist for between 5 and 20, weekly, or fortnightly sessions. Each session will last between 30 and 60 minutes. Some CBT therapists work with the techniques influenced by Beck and some work with the techniques influenced by Ellis. Most draw on both Handout with process Then worksheet

CBT 1 Beck’s Cognitive Therapy Beck developed a therapy to challenge the negative triad (beliefs) of the client.   First, the client will be assessed to discover the severity of their condition. The therapist will establish a baseline (or starting point), prior to treatment, to help monitor improvement.

Beck’s Cognitive Therapy The therapist must make the client aware of the relationship between thought and emotion:  I am stupid  This makes me feel sad I feel sad so I am not enjoying myself

Thoughts influence emotions and behaviour. To feel better you must think positively. The client is asked to provide information about how they perceive themselves, the future and the world. The therapist would use a process of reality testing e.g. if the client says, ‘I’m useless, and I always fail’, they will be asked whether in reality, they have been successful at something. The therapist might ask the client to do something to demonstrate their ability to succeed.

The client’s beliefs are directly challenged Clients are made aware of their negative views. In this way, irrational ideas can be replaced with more optimistic and rational beliefs. Through this process, irrational ideas can be replaced with more optimistic and balanced beliefs.  

CBT 2 Ellis’ Rational Emotive Behaviour Therapy REBT extends the ABC model to an ABCDE model D = Dispute (challenge the thoughts) E = Effect (see a more beneficial effect on thought and behaviour) Therefore the central technique of REBT is to identify and dispute the patient’s irrational thoughts

REBT Ellis (1962) argues that irrational thoughts are the main cause of all types of emotional distress and behaviour disorders. REBT is based on the premise that whenever we become upset, it is not the events taking place in our lives that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc. Ellis believed that irrational beliefs make impossible demands on the individual, leading to anxiety, failure and psychological difficulty REBT challenges the client to prove these statements, and then replace them with more reasonable realistic statements (empirical disputing/logical disputing).

Common irrational thoughts Ellis identified what he saw as the most common faulty beliefs experienced by people with mental health problems. I am worthless unless I am competent at everything I try I must be approved of and loved by everyone I meet My unhappiness is always caused by external events; I cannot control my emotional response It is upsetting when things are not the way I would like them to be Certain people are thoroughly bad and should be severely blamed or punished for it Because something once affected my life, it will do so indefinitely There is always a perfect solution to human problems and it is awful if it is not found I should depend on others who are stronger than I am It easier to avoid difficulties and responsibilities than to face them If something unpleasant happens I should keep dwelling on it

Newark et al (1973) AIM: They wanted to discover if people with psychological problems had irrational attitudes METHOD: Two groups of participants were asked if they agreed with the following statements identified by Ellis as irrational: It is essential that one be loved or approved of by virtually everyone in the community One must be perfectly competent, adequate and achieving in order to consider oneself worthwhile One group consisted of people who had been diagnosed with anxiety. The other group had no psychological problems. They were defined as ‘normal’. RESULT: A total of 65% of the anxious participants agreed with statement a) compared to 2% of non-anxious participants. For statement b) 80% of anxious participants agreed, compared to 25% of non-anxious participants CONCLUSION: People with emotional problems think in irrational ways

How effective is CBT? CBT is effective CBT is effective in reducing symptoms of depression and in preventing relapse and there is a large body of evidence to support this (March et al, 2007) It is the most effective psychological treatment for moderate depression. It is as effective as antidepressants for many types of depression (Fava et al, 1994).

How effective is CBT? CBT may not work for the most severe cases In some cases depression may be so severe that patients cannot motivate themselves to engage in the therapy In these cases, it is possible to treat the patient with antidepressants and then CBT can commence at a later date This is therefore a limitation as it means that CBT cannot be used as the sole treatment in all cases

CBT and Drug Treatment Keller et al (2000) Recovery rates (from depression) 55% drugs alone 52% CBT alone 85% when used together.

Success may be due to the therapist-patient relationship How effective is CBT? Success may be due to the therapist-patient relationship Research has shown that there is little difference between CBT and other forms of psychotherapy It may be the quality of the therapist-patient relationship that makes the difference to the success of the treatment rather than the treatment itself Simply having the opportunity to talk to someone who will listen could be what matters most

How effective is CBT? Some patients may want to explore their past CBT focuses on the ‘here and now’ however there may be links to childhood experiences and current depression and patients might want to talk about these experiences They can find this ‘present-focus’ very frustrating An over-emphasis on cognition There is a risk that in focusing on what is happening in the mind of the individual may end up minimising the importance of the circumstances the individual is living in There is thus an ethical issue for cognitive behavioural therapists here, and it is important for therapists to keep in mind that not all problems are in the mind.

Strengths Weaknesses Clients can become dependant on their therapist, or non-cooperative CBT is not effective for people with rigid attitudes or resistance to change, or for people who have high stress levels in response to genuinely difficult life circumstances (depressive realism) CBT is not a quick fix. A therapist is like a personal trainer that advises and encourages - but cannot 'do' it for the client. Client is actively involved in their recovery CBT is not physically invasive Client learns to help themselves, and can use the skills in new situations. CBT works (e.g. Mrach, Fava) Particularly when combined with drug treatment (Keller)

CHANGE VIEW: 10 key facts about CBT Change: your thoughts and actions View: events from another angle Homework: practice makes perfect I can do it: self-help approach Action : don't just talk, do! Experience: test out your beliefs Need: pinpoint the problem Write it down: to remember progress Goals: move towards them Evidence: shows CBT can work

"We are what we think. All that we are arises with our thought "We are what we think. All that we are arises with our thought. With our thoughts, we make our world." The Buddha

(12 marks – AS/16 marks A level) Essay Describe and evaluate cognitive behaviour therapy as a treatment for depression (12 marks – AS/16 marks A level)

Implications for the economy 4.2.3.1 Scientific processes: The implications of psychological research for the economy i.e. how knowledge of psychology is of benefit to employers Anything to do with treatment of mental disorders and people’s ability to work and contribute as effective members of society would be relevant - such as, finding an effective treatment (for any disorder) would reduce the number of days people have off work sick so improving productivity .

Implications for the economy The World Health Organisation (WHO) have predicted that by 2020, depression will be the biggest single disease burden, costly to individuals, families, communities and the economy as a whole through lowered productivity, absenteeism and unemployment Therefore, if psychological research shows that people with a disorder such as depression are less likely to suffer a relapse after having cognitive therapy then, even though cognitive therapy might initially be more expensive than drug therapy, in the long-term it might be more economically sound to offer cognitive therapy as people would have less time off work.