1. CBT for Depression: An Introduction
Florence Nightingale School of Nursing & Midwifery
CBT for Depression: An Introduction
Debbie Spain
Tutor – Dept. of Mental Health

2. Learning outcomes By the end of the session, you will be able to:
Define depression
Outline behavioural and cognitive models of depression
Discuss the application of key CBT principles and strategies
Begin to critique the evidence-base

3. Low mood: a continuum of experience?
Is it ‘normal’ to feel sad?
Are there any differences between sadness, grief
and depression ?
When does ‘normal sadness’ become depression?
(Horwitz and Wakefield, 2007) 3

4. Depression: diagnostic criteria (WHO, 1992)
Core symptoms:
Low mood
Pervasive loss of interest or pleasure (anhedonia)
Significant weight change
Sleep disturbance
Observable agitation or retardation
Loss of energy
Feeling worthless or unnecessarily guilty
Poor concentration or attention
Recurrent thoughts of death or suicide
Pattern must be present for most of the day for at least two weeks
Causing impairment and some interference to daily functioning 4

5. Depression: key stats Incidence:
Depressive episode = % of adults
Dysthymia = % of adults (NICE, 2010)
By 2020, depression will be the second cause of global disability and burden (WHO, 2010)
High rates of physical and mental health co-morbidities 5

6. Depression: key stats
Positive associations found between depression and the following (e.g. Gilbert, 2000; NICE, 2010):
- Gender
- Socio-economic status
- Social factors
- Adverse life experiences
- Physical illness 6

7. Depression: aetiology (NICE, 2010)
Contributory factors for depression may include:
- Neuro-biological factors
- Genetic predisposition
- Physical illness
- Stress vulnerability / social factors
- Psychological models
- Behavioural model
- Cognitive model 7

8. CBT: key principles
“Man is not affected by events but by the views he takes
of them” (Epictetus)
Links between thoughts, feelings and behaviour
Emphasis on the ‘here and now’
Important to establish current maintaining factors 8

9. Depression: aims of CBT assessment ?
Obtain information about current symptoms and impact
Develop a shared understanding (a formulation)
Provide psycho-education about CBT
Normalise experiences
Start to develop a therapeutic relationship
Instil hope
Risk assessment
Identification of clinically appropriate intervention/s
(e.g. Mulhern, 2010; Townend and Grant, 2010) 9

10. Depression: CBT assessment
Questions to consider:
Are there any symptoms of depression that might impact on undertaking an assessment?
Why might it be important to normalise experiences?
Why might it be important to instil hope?
What factors might render psychological interventions unsuitable for someone who is depressed?
How can we improve the process of assessment? 10

11. CBT models for depression
Behavioural model – Behavioural Activation
Cognitive model – cognitive therapy
Cognitive-behavioural models – cognitive and behavioural techniques 11

12. Behavioural model: background
Based on learning theory:
- Classical conditioning
Pavlov - stimulant induces a response
- Operant conditioning
Skinner – behaviour induces a response
(Tyrer and Steinberg, 2008)
Symptoms and behaviour are the disorder

13. Classical and operant conditioning

14. How do behaviours maintain and perpetuate low mood?
Developing a formulation 14

15. Behavioural model: Theories of depression Loss of response-contingent positive reinforcement (Skinner, 1953)
Stimulus e.g. work, social occasions, telephone calls absence of positive low mood, no interest, consequences or reward no energy, no motivation Response inactivity, procrastination, isolation 15 15

16. BA: a theoretical framework16

17. BA: Formulation Functional analysis TRAP: - Triggering events
- Responses
- Avoidance Patterns
TRAC:
- Triggering events
- Responses
- Alternative Coping 17

18. BA: treatment rationale
BA aims to re-establish the sense of achievement and
enjoyment out of everyday life by:
Increasing the amount, range, and difficulty of
activities
Balancing different types of activities
Taking the time necessary for task completion 18

19. BA: overview of treatment
Activity monitoring
Activity rating (MASTERY & PLEASURE)
Activity scheduling
Activity grading 19

20. Activity monitoring / scheduling
Tue
Wed
Thu
Fri
Sat
Sun
5-6am
6-7am
7-8am
8-9am
9-10am
10-11am
11-12pm
12-1pm
1-2pm

21. Activity rating
Rate each activity using a scale 0-8; 0 meaning “not at all”
and 8 meaning “very much”
Put a P with the rating next to activities that may give pleasure and enjoyment (e.g. watching TV, eating)
Put an M with the rating next to activities that may give a sense of achievement (doing the housework, taking kids
to school) 21

22. Activity scheduling Use a diary to plan hour-by-hour activities
Schedule in tasks so as to increase the activity levels
Schedule in tasks which the person has to do in balance
with tasks that the person wants to do, so as to
maximise mastery & pleasure 22

23. Activity grading Graded task assignment Four potential outcomes:
1.  Omit, if the tasks exceed the available time
2.  Delegate, wherever possible
3.  Seek help and support whenever possible
4. Grade the task 23 23

24. BA: the evidence base
Cuijpers, P. et al. (2007). Behavioural activation treatments of
depression: A meta-analysis. Clinical Psychology Review, 27, 318
326.
Mazzucchelli, T. et al. (2009). Behavioural Activation Treatments
for Depression in Adults: A Meta-analysis and Review. Clinical
Psychology: Science and Practice, 16(4), 24

25. Cognitive model: background
Thinking and cognition shape our view of the world
The ABC model (Ellis, 1962):
Activating event
Beliefs about activating event
Consequence (emotional or behavioural) of belief
(Tyrer and Steinberg, 2008)

26. Cognitive model: A Beckian formulation (Beck 1976)
Early
Experience
Core Beliefs
About self/others/world
Rules and
Assumptions
Conditional statements
If………..then
Situations or events where rules
are broken or assumptions activated
Critical
Incident
Emotion
Physical
Thoughts
Behaviour 26

27. Cognitive model: key aspects
Thoughts and thinking style likely contribute to the development and maintenance of depression
Depression exaggerates processes inherent in all of us:
a continuum of functioning
Depression affects the way we view ourselves, the world and other people
(Mulhern, 2010) 27

28. Cognitions: contributing to development and persistence of depression?
Content: themes of loss, self devaluation, hopelessness
Process:
- bias towards the negative
- reduced flexibility
- cognitive style
Interpretation bias:
- negative events are explained by internal factors
- positive events are explained by external factors not attributed to self
Bias results in an absence of positive experience past and present

29. Common thinking styles
Jumping to conclusions
Predicting the future
All or nothing thinking
Emotional reasoning
Discounting the positive
Catastrophising
Dwelling on the negative
Egocentric thinking
Rumination
Reduced meta-cognitive awareness
(Gilbert, 2000)

30. Cognitive therapy: planning treatment
Treatment plan is informed by conceptualisation
Structured and time limited
Focus upon maintaining factors
Collaborative, not confrontational
Reliant upon guided discovery not didactic
Socratic questioning is key
Educational - promoting self application of CBT skills

31. Cognitive interventions
Cognitive interventions broadly address:
- What the person thinks (the content)
- The way they think (the process)
- Their interpretation of their thinking and events (the meaning) 31

32. Cognitive interventions contd.
Some common cognitive interventions: - Identifying and challenging negative thoughts - Continuums - Behavioural experiments - Surveys - Role plays 32

33. One thought leads to another. And another. And another…
NATs have several characteristics:
seem to occur automatically, without any effort
typically followed by a string of other thoughts
appear logical and plausible
often distorted
unhelpful
involuntary 33

34. Challenging negative automatic thoughts
Helpful to consider the following:
What is the evidence for and against my thoughts?
What is the effect of thinking the way I do?
What alternative views are there?
What thinking errors am I making? 34

35. Continuum work Use of continuums to explore thoughts and beliefs is
very common
This is not about telling people that their thoughts are wrong
A way of generating further evidence about a situation
Involves guided discovery and socratic dialogue
Ideal to write things down 35

36. Behavioural experiments: an overview
A way to test out beliefs
Informed by a shared formulation
Identify the specific belief to test
Rate the strength of belief
Devise a way of testing this out
Make predictions
Identify and problem-solve around any obstacles
Drop safety-behaviours
Conduct experiment
Rate outcome, belief 36

37. Planning therapy How do you decide which interventions to use first?
Positive outcomes in cognitive therapy for depression may be predicted by the extent to which early sessions focus on specific concrete interventions (Feeley et al 1999)
Key questions to consider when deciding which strategies to use with individuals and at what stage:
How severe is the depression?
At what point in therapy is the client?
What problem is most distressing to client?
What area is most amenable to change?
Risk issues 37

38. NICE stepped care model for depression (2010)38

39. Developing a therapeutic alliance
The importance of the therapeutic relationship?
“A good relationship between client and therapist is, at the very least, considered to be the base from which all therapeutic work takes place” (Hardy et al. 2007, in Grant
& Townend, 2010)
Threats to the therapeutic relationship?
Key components of effective therapeutic relationships? 39

40. Goal setting in depression
Important to identify personally
meaningful goals
Be pragmatic
Plan for contingencies
Helpful to record goals and
successes promptly 40

41. ‘Homework’ contd. The importance of homework? Homework in practice
Understanding reasons for non-completion of tasks is an important aspect of CBT therapy 41

42. Outcome measures in depression
Standardised measures e.g. CORE-OM, HADS, BDI
Idiosyncratic measures
Subjective units of distress (SUDS rating) 42

43. Keeping track of who said what during therapy sessions?
“I know you think you understood what you thought I said, but I don’t think you understood that what you heard is not what I meant” 43

44. Additional interventions and relapse prevention
Looking after physical health
Exercise
Be aware of triggers for stress
Sleep hygiene
Problem-solving techniques
Assertiveness training
Addressing low self-esteem
Mindfulness-based cognitive therapy
Compassionate-focused therapy
Follow up sessions
Relapse prevention
Create a self-help tool box: “therapy blueprint” 44

45. CBT: Therapy blueprint
Questions to consider:
What are my ongoing problem areas?
What are my beliefs, assumptions that keep these problems going?
What have I learnt in therapy?
What CBT skills do I have?
What are the potential obstacles in the future that may influence my mood / prevent me from using my CBT skills?
What resources are available to me? 45

46. Some considerations
CBT for depression typically involves changing unhelpful / avoidance behaviours, and examining unhelpful thoughts and patterns of thinking
Increasing evidence for several modes of CBT delivery
Therapy outcomes are determined by several key factors including a shared formulation, consideration of non-specific variables, and ongoing assessment of risk and need
Proactive strategies are as important as reactive strategies 46

47. References
Cuijpers, P. et al. (2007). Behavioural activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27, Gilbert, P. (2000). Overcoming Depression. (2nd ed). London: Constable & Robinson. Horwitz, A. and Wakefield, J. (2007). The Loss of Sadness. Oxford: Oxford University Press. Keedwell, P. (2008). How sadness survived. The evolutionary basis of depression. Oxford: Radcliffe Publishing. Kuyken, W and Dimitrios, T. (2009). Therapist competence, Comorbidity and Cognitive-Behavioural Therapy for Depression. Psychotherapy and Psychosomatics, 78(1), Mazzucchelli, T. et al. (2009). Behavioural Activation Treatments for Depression in Adults: A Meta-analysis and Review. Clinical Psychology: Science and Practice, 16(4),

48. References
Mulhern, R. (2010). Depression. In A Grant, M Townend, R Mulhern and N Short (2010). Cognitive Behavioural Therapy in Mental Health Care. London: SAGE. Neff, K. NICE. (2010). CG90 – Depression. London. HM Publications. Richards et al (2012) Computer-based psychological treatments for depression: A systematic review and meta-analysis. Clinical Psychology Review. 32, 4, Townend, M. and Grant, A. (2010). Fundamentals. In A Grant, M Townend, R Mulhern and N Short (2010). Cognitive Behavioural Therapy in Mental Health Care. London: SAGE. Tyrer, P. and Steinberg, D. (2008). Models for Mental Disorder: Conceptual Models in Psychiatry. (4th ed). Chichester: John Wiley & Sons. WHO. (1992) ICD-10. WHO. 48