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Cognitive Behavioral Therapy for Depression – Does it Work?

What is the Difference Between Behavior and Cognitive Psychology?

Principles from the behavior school of psychology and from the cognitive school of psychology were used to develop different forms of psychotherapy that were separate, but compatible. Behavioral psychology concentrates on using observable factors to change observable behavior, whereas cognitive psychology focuses on an individual’s attitudes, perceptions, and belief system as the driving force behind behavior. Behavioral therapy concentrated on the principles of behavioral psychology, whereas cognitive therapy concentrated on the principles of cognitive psychology as mechanisms to induce change in people.

Even though the roots of psychotherapy go back far beyond Sigmund Freud, most sources acknowledge Freud as the founding father of modern psychotherapy, as he was the first person to use a sort of “talking cure” to treat known mental health disorders. Freud’s ideas were first met with enthusiasm; however, over time, they began to lose popularity with certain individuals, especially individuals who were driven to use experimental methods to validate psychological principles. The marriage of experimental psychology and psychotherapy resulted in the merging of the psychological schools of behavioral psychology and cognitive psychology, both of which were very different from traditional Freudian notions of how behavior was expressed and the role of the mind and behavior.

As mentioned above, these two separate paradigms are very compatible with one another. Clinicians eventually merged the principles of cognitive therapy and behavioral therapy/psychology to form a broad school of psychotherapy that is termed Cognitive Behavioral Therapy. This article will discuss the basic principles of Cognitive Behavioral Therapy for depression and for the treatment of substance use disorders; however, the information in this article is designed to be used for educational purposes. Only trained, licensed, therapists can apply the principles of Cognitive Behavioral Therapy.

Cognitive Behavioral Therapy and Depression

Cognitive Behavioral Therapy (CBT) is a family of different psychotherapies that operate on the same basic general principles. There is no one form of CBT. The major principle embraced by CBT is that people develop irrational belief systems that result in a number of different issues, including the development of certain types of psychological disorders. The core mechanism of change for any form of CBT is to identify the specific irrational beliefs of the individual, work with the individual to challenge these deep-rooted beliefs, and then work with the individual to change these beliefs in a manner that will foster a positive outcome for the person.

As mentioned above, CBT consists of a number of different types of therapy based on these underlying principles. Some of the more well-known forms of CBT include:

  • Rational Emotive Behavioral Therapy (REBT)REBT assumes that everyone has developed a specific set of assumptions regarding the world and themselves that they use to guide them on how to behave in certain situations. For the most part, these assumptions are functional; however, in some cases, individuals accept certain assumptions that are unrealistic, irrational, and may be inappropriate. These assumptions can lead to a number of dysfunctional behaviors and even to formal disorders, such as depression or substance use disorders. The goal of REBT is to confront the individual regarding their irrational beliefs, identify them, challenge them, and help the individual change them to beliefs that are more in line with reality. As the therapy progress, certain aspects of dysfunctional behaviors are addressed and changed.
  • Acceptance and Commitment Therapy (ACT)ACT attempts to get individuals to accept realistic appraisals of themselves such that they do not make global statements regarding their effectiveness or ineffectiveness. For example, an irrational belief is continually thinking, “I am a bad person.” Instead of thinking in those terms, ACT attempts to get the individual to recognize what they are really feeling which is more along the lines of something like, “I am feeling ineffective at this time.” This allows individuals to rid themselves of global labels and accept reality. Once this is done, individuals can confront these negative feelings and change themselves for the better.
  • Dialectical Behavior Therapy (DBT): DBT is a type of Cognitive Behavioral Therapy that has found its use in treating severely depressed individuals or individuals with severe personality disorders, such as borderline personality disorder, by addressing their dysfunctional thinking patterns and helping people change these beliefs.
  • Motivational Interviewing (MI)MI assumes that not everyone is aware of their need to change and that different people view their situation differently. MI has developed a model that identifies where the person stands on their understanding of their need for change and then adjusts the treatment according to that person.
  • Interpersonal Therapy (IT)IT focuses on relationships and communication patterns. Interpersonal therapy is typically short in duration and attempts to use a highly structured approach to solving a client’s issues. IT is often used for the treatment of depression but can be used in the treatment of other issues as well. It’s highly focused approach, structured format, and straightforward and practical principles make it ideal for individuals who do not wish to participate in lengthy periods of therapy that continue past two or three months.
  • Other formsA number of other different therapies exist, including CBT for substance abuse, specialized forms of CBT for anxiety disorders, CBT for depression, etc. All of these operate on the same general principles mentioned above but are adjusted for the specific types of disorders they are designed to address.

The Core Principle

As mentioned above, the primary principle of CBT is that individuals develop irrational and dysfunctional patterns of thinking that lead to irrational and dysfunctional behaviors. The core idea of any form of CBT is to address this irrational belief system in such a manner that it is identified, confronted, and changed. Then, the individual can change their behavior accordingly. CBT uses a number of different techniques from cognitive therapy and behavioral therapy.

While the core principles of CBT are rather easy to state in a simplistic manner, this should not be taken to infer that CBT is an easy therapy to learn and use. There are number of misconceptions that individuals have regarding CBT. The first one is that CBT is simple and straightforward to perform; however, it takes years of training to be able to understand the intricacies of the principles of CBT and to be able to implement them in an efficient manner to individuals who are in distress. Second, many individuals believe that CBT ignores the past history of the client. Nothing could be further from the truth. CBT uses the past to reconstruct the development of the person’s irrational belief system and to help understand it. A final misconception regarding CBT is that it is a simple collection of techniques and not a unified therapy. However, as mentioned above, there are different schools or types of CBT that are designed to be used in specific types of situations or for specific types of disorders. CBT is a family of psychotherapies all operating on certain general principles that are applied differently depending on the situation.

However, the first core principle, addressing irrational beliefs, typically focuses on irrational beliefs that occur regarding:

  • Oneself: Many individuals develop dysfunctional beliefs about themselves, such as, “I must always seek approval of others,” or “If I fail at something, I am a bad person.”
  • The world or one’s environment: Individuals may develop a number of unrealistic and irrational beliefs about the state of the world or how other people act, think, or feel. For example, individuals with substance use disorders often share an unrealistic belief like, “Everyone uses alcohol so using alcohol in the manner that I do is normal.” Although the majority of people report using alcohol at least once in life, not everyone uses alcohol. Other irrational beliefs about the world include ideas like “life is unfair,” which is a statement that can never be confirmed because no one can really define what fairness in life is. Fairness often represents a subjective appraisal.
  • The future: Individuals with substance use disorders often believe that in order for them to be happy, they must use their substance of choice (a totally irrational belief) or that using their substance of choice makes them happy (despite all the dysfunctional and negative aspects associated with their substance use). Individuals who are depressed often have a pessimistic outlook on future events.

An Overview of Treatment Using CBT

The different methods of CBT typically follow a structured approach that distinguishes CBT from other types of psychotherapy.  A basic outline of the approach follows:

  • Assessment: In the initial stages of treatment, the therapist will create a functional analysis of the person’s situation as it relates to their mood (in cases of individuals depression) or of their substance use (individuals with substance use disorders). This includes understanding the antecedents of the individual’s problem, such as the types of thoughts that drive the individual’s behavior and the conditions that drive it, the actual behavior itself (whether it involves issues associated with depression or substance use), and the consequences of the individual’s actions, including how they think and feel, and other conditions that may reinforce their behavior. In behavioral psychology, this is often referred to as the ABCs of behavior.
  • Identification: As part of the overall functional analysis described above, the therapist will also attempt to work with the individual to identify the core illogical or irrational patterns of thinking that drive the individual’s depression or substance use.
  • Recognition: The therapist will then work with the individual to have the individual recognize their own dysfunctional patterns of thinking and irrational belief system. As the therapist and client do this, the therapist will begin to have the individual challenge these irrational thoughts and beliefs in an effort to have the client cast them in reality. Since they are irrational, they can never stand this type of reality testing.
  • Cognitive restructuring: As certain attitudes and beliefs are identified as being unrealistic and irrational, the therapist will help the individual develop more functional and realistic beliefs, attitudes, problem-solving skills, and plans of behavior for acting in the world.
  • Homework and practice: Throughout the process, the therapist will work with the individual in therapy sessions and also give the individual homework assignments to practice regarding recognizing, challenging, and changing dysfunctional beliefs and patterns of thought. These assignments are reviewed in sessions.
  • Competence: As the process moves forward, the client will become more adept at understanding their own tendencies toward irrational thinking, the origins of these dysfunctional and irrational beliefs, and how to address them. The therapeutic process attempts to move the individual toward autonomy.
  • Follow-up care: The therapist will schedule follow-up sessions as needed as the individual begins to move toward autonomy. Follow-up sessions fine-tune the process and address any new issues.

Effectiveness for Depression

CBT is one of the most researched forms of psychotherapy, and there are numerous empirical studies that have demonstrated its treatment effectiveness for a number of different types of issues, including depression, anxiety disorders, substance use disorders, personality disorders, and many other issues. CBT is often mentioned as the preferred form of psychotherapy for certain types of psychiatric and psychological disorders, including major depressive disorder, personality disorders, anxiety disorders, trauma and stress-related disorders, substance use disorders, and a host of other disorders and issues.

Nonetheless, CBT is not a cure-all, and there are certain types of issues that CBT is not designed to address, including individuals who are actively psychotic (e.g., having hallucinations and delusions) or people who have a significant cognitive limitations that affect their ability to reflect and use problem-solving techniques. In addition, no form of psychotherapy will be embraced by everyone or can be applied under every circumstance. Research studies demonstrating the effectiveness of psychotherapeutic techniques, such as the various forms of CBT, basically indicate that these interventions are generally effective for most individuals; however, there is no research study that guarantees that any form of psychotherapy will be effective for any individual in particular or will address any particular situation in an adequate manner. However, as far as the different forms of psychotherapy are concerned, the different types of CBT are generally considered to have the best empirical support for their use in a number of different situations.