Cognitive Behavioral Therapy (CBT) has been widely adopted in the treatment of depression, and empirical studies have reported its efficacy. The model which was developed in the 1960s by Beck following the recognition that depression was a result of dysfunctional thinking has evolved to accommodate the needs of diverse clients to make it effective in the treatment of patients in all parts of the world. The paper presents the application of CBT in the treatment of Lara, a biracial woman aged 27 years and diagnosed with depression at the age of 13 years. The paper will start by analyzing the assessment of the client using the cognitive model. Second, the paper will focus on cognitive distortions and adaptive responses in light of diversity. Next, the paper examines how a therapist and client identify treatment goals. The last section will critique the use of the CBT model for individuals with depression. The paper found that CBT reduces the symptoms of depression by helping a person to recognize distorted thoughts and replacing them with what reflects reality. However, the model requires the incorporation of socio-cultural components to address the need of diverse clients to remain an efficacious model for millions of depression patients around the world.
Keywords: cognitive model, depression, clinician, therapist, client, treatment
Cognitive Behavior Therapy
Depression is a life-threatening condition that reduces the quality of life. It has detrimental effects on health and causes impairment in social function needed for healthy development. Since the 1960s, it is a well-known fact that dysfunctional thoughts predispose an individual to depression following an experiment by Aaron Beck that led to the development of an effective treatment that focuses on individual cognition and behaviors. Beck noted that negative behavior and mood observed in depressed patients are a result of distorted cognitions and core beliefs and not events themselves (Beck, 2011). The discovery led to the development of fundamental concepts of cognitive-behavioral therapies (CBT) which have proved to be effective in reducing depression symptoms. In the case study, Lara, a 27-year-old biracial woman diagnosed with depression at the age of 13, faced many challenges since her childhood. Lara thinks negatively and magnifies her problems. According to Hofmann, Asnaani, Vonk, Sawyer, and Fang (2015), CBT has the greatest empirical support among all psychotherapeutic options in the treatment of depression. Lara can be subjected to CBT to improve her condition by focusing on her thoughts and reaction to situations. CBT can help Lara develop a set of skills needed to understand how behaviors and thoughts influence her emotions and improve her feelings. The mechanism implies the replacement of detrimental cognitions with realistic and accurate perceptions (Luna-Barco, 2016). It is reasonable to consider the application of CBT in the treatment of Lara’s depression, analyzing the assessment of the client, cognitive distortions and adaptive responses, goals for a treatment plan, and critique of the use of this model for depression patients.
Client Assessment Using CBT
The cognitive model involves the identification and reframing of maladaptive thoughts. Therapists who apply this model are reliant on cognitive restructuring to question the client’s thoughts and reframe them if they are unhelpful or irrational (Beck, 2011). During the first session, the clinician must first examine Lara’s background to understand her behavior and identify the problematic behavioral cycles and other issues that should be targeted throughout treatment. After identifying the target behaviors, therapists assess the antecedents that trigger the core beliefs and thoughts that mediate the problem.
For depressed patients, a comprehensive assessment is needed to identify behaviors responsible for the development of the illness and recognize Lara’s behaviors reflective of depression to make a correct diagnosis and design appropriate intervention. According to Ledley, Marx, and Heimberg (2010), the process of assessment involves two goals, namely diagnosis and case conceptualization that guide the treatment. Diagnosis skills are honed only through experience, but assessment can be done with the knowledge of diagnostic classification. Clinicians must familiarize themselves with diagnostic criteria for depression. They should know the features of depression and the ways to perform a differential diagnosis. The use of semi-structured clinical interviews has proven useful in making the correct diagnosis.
The conceptual framework describes how the symptoms began and what maintains them. According to Beck (2011), conceptualization helps clinicians understand why Lara currently reacts to the problems and situations in the way she does. The formulation of the conceptualized case helps therapists to identify Lara’s behaviors and cognitions that should be targeted in therapy. It increases therapists’ confidence in their clinical decisions in the course of working with clients. Accordingly, clinicians can develop conceptualized cases by conducting a thorough assessment to understand the problem and the current focus of treatment.
Cognitive therapy is grounded on a cognitive model, which suggests that dysfunctional or distorted thinking underlies all psychological disorders. Although there are variations in cognitive behavior theories, all of them propose that psychological problems such as maladaptive behaviors and negative emotions are maintained by the way people perceive the event. Therefore, Lara’s beliefs about the situations that happen to her influence her behaviors and not the events themselves. Beck delineated three levels of cognition that affect the way people interpret the world, namely core beliefs, conditional beliefs, and automatic beliefs. Wenzel (2012) defines core beliefs as absolute, inflexible, and generalized beliefs that are shaped by individual experiences and determine the way one interprets reality. The cognitive model proposes that core beliefs influence automatic thoughts and conditional beliefs, and they are activated whenever people are exposed to traumatic events.
Negative automatic thoughts are images or thoughts formed in an individual’s brain and characterized by a cognitive triad, which suggests that depressed patients expect unfavorable outcomes for their problems and negatively describe their experiences. This is evident in the case of Lara who views her experiences from a negative perspective. Lara has been confronted by unfavorable life situations such as difficult relationships, family instability, and physiological loss, which led to depression. Other situations include a break-up with her partner and pressure from family members and friends who expect too much from her. The problem is that instead of endorsing positive self-referent thoughts, Lara thinks negatively about herself and her future, which makes her condition more severe. Due to her negative automatic thoughts, Lara is unable to attend classes. Her most atypical thoughts that demonstrate her negative view is the lack of confidence that she can ever finish a degree, gain employment and become independent. Consequently, such an approach to interpreting situations and expectations triggers depressive behaviors that lead to the misinterpretation of the event (Beshai, Dobson, Adel, & Hanna, 2016). Endorsing negative automatic thoughts also provokes the feeling of hopelessness, inadequacy, and low self-esteem.
Lara’s depressive schemas are a result of dysfunctional attitudes and negative thoughts. She believes that she will never finish school and become independent. Lara’s depressive situation activates the negative schemas, which lead to increased dysfunctional thinking and attitude towards her life. Failure to question her beliefs and thoughts predisposes Lara to interpret situations in a negative way (Ledley, Marx, & Heimberg, 2010). In assessing the client, the clinician should consider the three levels of cognition to identify how Lara’s thoughts, beliefs, and resultant behaviors maintain the depression. After assessing the patient’s concerns, the clinician should develop a hypothesis and a treatment plan. Therapists can identify the automatic thoughts and underlying assumptions during assessment and early intervention period, whereas core beliefs are identified at the later stage after observing repeated themes across situations (Beck, 2011). Conceptualization of the levels of cognition can help therapists to implement intervention effectively.
Cognitive Distortions and Adaptive Responses
The goals of CBT are to understand how distorted thinking adversely affects an individual’s ability to cope with stressful events and to help the client identify cognitive distortions in their automatic thoughts, evaluate these distortions critically, and challenge them by developing adaptive responses. According to Rnic, Dozois, and Martin (2016), human memory is imperfect and prone to distortions that can have serious consequences by increasing individual vulnerability to psychological problems. Beshai et al. (2016) assert that cognition distortions play a central role in depression. People suffering from depression are not flexible in structuring their experiences, and this leads to systematic errors in the interpretation of events regarding the judgment of the external situation and personal performance.
Cognitive distortions in individuals with depression can be grouped into typological systems that include personalization (personal and negative attributes), overgeneralization, selective abstraction, and arbitrary interference (Luna-Barco, 2016). For instance, Lara’s conclusion about her education and future was not premised on sufficient evidence, and she tends to consider that one negative situation will occur again. Cognitive distortions occur at varying frequencies given the dysfunctional rules, assumptions, and individual core beliefs acquired throughout the lifetime of an individual with depression.
CBT helps clients to replace dysfunctional thoughts with adaptive responses through the process of re-learning. Cognitive distortions are a psychological defense associated with individual responses to events. Altering Lara’s perception may lead to adaptive responses, which may help her develop coping strategies. According to Hayes, VanElzakker, and Shin (2012), cognitive distortion is a useful mechanism for reducing the impact of traumatic events through maintaining functional schemas or necessary relationships. The clinician can teach Lara about cognitive distortions, for example, magnification and arbitrary interference, to help her create an adaptive response as her knowledge of distorted thinking increases. When Lara recognizes her cognitive distortions, the act of recording her reaction to an event serves as a cue to initiate adaptive coping strategies.
Although CBT is widely used, its level of efficacy and appropriateness with non-Western individuals is questioned because it is a Western construction. According to Luna-Barco (2016), cultural factors influence depression presentation among people from various cultures. Traditional psychological practices are not effective for clients who are not members of non-dominant cultural groups because they do not address their experiences, values, and worldviews. Hofmann et al. (2015) suggest that core CBT strategies such as gradual steps, experimentation, logical discourse, and empirical analysis are not adequate to alter the dysfunctional thoughts and maladaptive behaviors of oppressed individuals or those with characterological challenges. The strategies are reliant on scientific methods, individualism, and logic, which fail to respond to the diversity and complexity of human experience because they overlook the importance of collectivism, spirituality, and mysticism. In another study, Beshai et al. (2016) found that cultural factors influence the effectiveness of the CBT model; thus, treatment should be tailored to make the model more appropriate and efficacious for people with different cultural backgrounds. CBT needs to be tailored to address the need of diverse clients to remain an efficacious model for millions of depression patients around the world.
CBT’s flexibility has allowed therapists to introduce other theoretical perspectives such as motivational interviewing and commitment therapy to bridge the gap. According to Luna-Barco (2016), CBT has shifted from radical behaviorism to integrative worldviews through the integration of Eastern-based worldviews such as acceptance and mindfulness. Practitioners and theorists are integrating CBT with new concepts that bring new perspectives to the model to ensure that it becomes a culturally sensitive practice. The undergoing transformation of the CBT achieved by incorporating knowledge from different socio-cultural backgrounds with diverse values allows theorists and therapists to enhance the efficacy of their practice. According to Hoffman et al. (2012), therapists can transform their practice into more anti-oppressive, inclusive, and liberating by considering individual belief systems. Creating awareness about systemic issues that constrict and limit clients’ lives may increase clinicians’ competence and enhance the effectiveness of their practice.
Individuals from non-dominant groups suffer from internalized oppressions, which affect self-esteem and may lead to depression. The assessments of individual historical and cultural contexts help therapists gain an insight into the client’s experiences. Lara feels like an outcast in her white middle school and high school due to her mixed ethnicity (African American /Asian). Originating from a racial minority group, Lara develops dysfunctional thinking or maladaptive beliefs, which make her feel psychologically distressed. Given the detrimental effects of race on individual worldviews, therapists must consider Lara’s cultural and historical context to identify the factors that maintain maladaptive behaviors and harmful cognitions. Luna-Barco (2016) posits that a comprehensive description of current and historical contexts can change a client’s core beliefs and automatic thoughts by creating new narratives. Taking into account historical and cultural context helps therapists to elaborate more comprehensive assessments and interventions to avoid perpetuating oppressive dynamics with clients.
Goal(s) Collaboratively for Treatment/Service Plan
Devising the case conceptualization leads to the evolution of the treatment plan, which prioritizes the materials collected during the assessment. The plan serves many purposes, including selecting optimal interventions for specific goals and identifying barriers to goal achievement. According to Ledley, Marx, and Heimberg (2010), modifications to the treatment plan are permitted in the course of treatment but take into account the adjustment of the case conceptualization. The development of a treatment plan begins with the identification of the treatment goal, which is the first activity to be completed in CBT. Goal setting occurs during the second session after assessment. A beginning clinician can use a treatment manual, which contains useful information such as the nature of the problem and how the treatment should proceed to devise a therapy structure and identity treatment goals.
Collaborative approaches have emerged as effective strategies for improving goal setting and helping clients feel respected. These approaches serve as building blocks for a healthy therapeutic alliance during treatment (Hayes et al., 2012). The clinician should involve Lara in determining the broader treatment goals based on the central issues. The broader goals should then be broken down into smaller ones to help Lara understand what to accomplish at every stage. The treatment goals must be specific, realistic, and tailored to her needs. A preliminary set of goals should be developed to maximize the benefit and applicability to the client. Four goals should be accomplished by the end of the therapy. The first goal is to help Lara cope with everyday life without feeling depressed or vulnerable. Second, is needed to increase Lara’s confidence to encourage her to go back to school to finish her degree and get employed. The third treatment goal is to resist friends and family members who expect too much from her. Lastly, the treatment will help Lara to find a loving partner. The goals should be modified or changed at any point in the course of the treatment.
In CBT, patients are given home assignments, which they are expected to take to the clinician during the next session. One of the home assignments for a client undergoing CBT is recording their daily activities. Clinicians encourage clients to record the activities after every event to prevent distorted thoughts resulting from memory difficulties and depressed moods. The clinician should work in collaboration with Lara to schedule the activities needed for improvements. Recording dysfunctional thoughts encourage the client to recall feelings, thoughts, and events and identify the productive dysfunctional automatic thoughts (Ledley, Marx & Heimberg, 2010). The clinician should also give Lara an assignment to engage in productive or enjoyable activities that improve her mood. The clinician helps the client to identify actions that reinforce positive feelings and thinking. Moreover, the clinician requests the client to record positive activities and their effects on their mood. The client is also requested to keep a list of questions that a clinician may have about the treatment process. Another home assignment is creating a list of things that the client wishes they could have changed and her concerns.
CBT for Treatment of Depression
CBT is a short-term therapy that focuses on how a client feels, thinks, and behaves in the present. It emphasizes the role of cognition in causing and maintaining problems associated with depression. CBT in depression treatment aims to improve the negative thinking patterns. According to Beshai (2016), CBT is a successful treatment for depression, and sometimes it has higher efficacy than other forms of psychological intervention and pharmacological therapy because it provides a durable response and may prevent reoccurrence. CBT also increases medication adherence and improves the symptoms of depression. Currently, CBT is well understood, and the therapeutic model for depression and its efficacy for severe, moderate, and mild depression is well known.
The cognitive component can improve individual thoughts and moods. Distorted thinking and negative behavior predispose an individual to depression. A CBT practitioner works with a depressed patient to identify distorted thinking and responses to stressful situations. CBT focuses on changing behavior patterns by creating opportunities for positive thinking. Distorted thinking affects Lara’s behavior, sense of self, and mood. Therapists can help the client identify distorted perceptions, recognize dysfunctional thinking, and find positive thoughts that reflect reality. Clinicians find evidence to support dysfunctional thinking and alternative views and apply cognitive restructuring to help clients generate accurate thoughts (Beshai et al., 2016). In depression treatment, cognitive therapy helps the client to consider if their beliefs are true about the reality leading to the identification of the factors that contribute to maintaining the problem.
The steps followed in the treatment of depression using CBT are well established. According to Hofmann et al. (2015), CBT practitioners follow three steps in treating depressed patients. In the first step, the clinician should identify the negative automatic thoughts. In the second step, the clinician emphasizes the client’s relationship with others. The third step focuses on the change that is needed to improve the client’s behavior to address the current problem. Cognitive therapy allows a collaborative approach in which the clients participate in their treatment. The behavior component focuses on the behaviors and actions. The onset and persistence of depression are associated with positive reinforcement. Excess of aversive experiences or decreased level of reinforcement from the outside world may lead to depression due to withdrawal from positive experiences and activities. A clinician can work collaboratively with the client to increase activities that result in social interaction and positive reinforcement. The treatment involves scheduling and monitoring a client’s actions (Hayes et al., 2012). Therapists also help depressed patients to modify their behavior, which increases the magnitude of the symptoms. Modification of Lara’s behavior will reduce depression symptoms and improve the quality of her life.
CBT model of depression makes an important distinction between self-statements or automatic thoughts and core beliefs. Its basic premise is that emotions cannot be changed directly; thus, they can be targeted by changing behaviors and negative automatic thoughts contributing to the problem. CBT is the most effective treatment option for depression, which is a result of cognitive distortions. The collaborative approach in the treatment of depression using CBT ensures that the therapist and clients implement the most appropriate intervention and work towards a mutually agreed goal to replace the negative thinking and behavior patterns with those that reflect reality.
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