Cognitive behavioral therapy (CBT) is an effective treatment for depression. At the heart of CBT is an assumption that a person's mood is directly related to his or her patterns of thought. Negative, dysfunctional thinking affects a person's mood, sense of self, behavior, and even physical state. The goal of cognitive behavioral therapy is to help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking.
At the same time, therapists who practice CBT aim to help their patients change patterns of behavior that come from dysfunctional thinking. Negative thoughts and behavior predispose an individual to depression and make it nearly impossible to escape its downward spiral. When patterns of thought and behavior are changed, according to CBT practitioners and researchers, so is mood.
How Does Cognitive Behavioral Therapy Differ From Other Depression Treatments?
The focus and method of cognitive behavioral therapy sets it apart from other, more traditional therapies:
- CBT is based on two specific tasks: cognitive restructuring, in which the therapist and patient work together to change thinking patterns, and behavioral activation -- in which patients learn to overcome obstacles to participating in enjoyable activities. CBT focuses on the immediate present: what and how a person thinks more than why a person thinks that way.
- CBT focuses on specific problems. In individual or group sessions, problem behaviors and problem thinking are identified, prioritized, and specifically addressed.
- CBT is goal oriented. Patients working with their therapists are asked to define goals for each session as well as longer-term goals. Longer-term goals may take several weeks or months to achieve. Some goals may even be targeted for completion after the sessions come to an end.
- The approach of CBT is educational. The therapist uses structured learning experiences that teach patients to monitor and write down their negative thoughts and mental images. The goal is to recognize how those ideas affect their mood, behavior, and physical condition. Therapists also teach important coping skills, such as problem solving and scheduling pleasurable experiences.
- CBT patients are expected to take an active role in their learning, in the session and between sessions. They are given homework assignments at each session -- some of them graded in the beginning -- and the assignment tasks are reviewed at the start of the next session.
- CBT employs multiple strategies, including Socratic questioning, role playing, imagery, guided discovery, and behavioral experiments.
- CBT is time limited. Typically, treatment with CBT lasts 14 to 16 weeks.
Who Can Benefit From CBT?
Anyone with mild or moderate depression can potentially benefit from cognitive behavioral therapy, even without taking medication. A number of studies have shown CBT to be at least as effective as antidepressants in treating mild and moderate depression. Studies also show that a combination of antidepressants and CBT can be effective in treating major depression.
CBT can be an effective treatment for mild and moderate depression in adolescents as well. It's also been shown to be effective at reducing relapses in patients who experience frequent relapses after having gone through other treatments.
Nearly two out of every three patients who are treated successfully for depression are treated with medications alone. Other patients, though, have lingering symptoms even when medication is partially working. CBT can be effectively used to treat many of these patients.
Although a wide range of people respond well to cognitive behavioral therapy, experts point out that the type of person likely to get the most benefit is someone who:
- Is motivated
- Sees him or herself as able to control the events that happen around them
- Has the capacity for introspection
What Is Cognitive Restructuring?
Cognitive restructuring refers to the process in CBT of identifying and changing inaccurate negative thoughts that contribute to the development of depression. This is done collaboratively between the patient and therapist, often in the form of a dialogue. For instance, a college student may have failed a math quiz and responded by saying, "That just proves I'm stupid."
The therapist might ask if that's really what the test means. In order to help the student recognize the inaccuracy of the response, the therapist could ask what the student's overall grade is in math. If the student answers, "It's a B," the therapist can then point out that his answer shows he's not stupid because he couldn't be stupid and get a B. Then together they can explore ways to reframe what the performance on the quiz actually says.
The "I'm stupid" response is an example of an automatic thought. Patients with depression may have automatic thoughts in response to certain situations. They're automatic in that they're spontaneous, negative, and don't come out of deliberate thinking or logic. These are often underpinned by a negative or dysfunctional assumption that is guiding the way patients view themselves, the situation, or the world around them.
Other examples of automatic thinking include:
- Always thinking the worst is going to happen. For instance, a person may convince himself he is about to lose his job because the boss didn't talk to him that morning or he heard an unsubstantiated rumor that his department was going to cut back.
- Always putting the blame on oneself even when there is no involvement in something bad that happened. For example, if someone did not return your call, you might blame it on the fact that you are somehow a very unlikeable person.
- Exaggerating the negative aspects of something rather than the positive. Think of someone who exercises a stock option from a bonus a week before the stock rises another 10%. Instead of enjoying the bonus money he just got, he tells himself he never gets the breaks or that he's too afraid to take risks that he should take. If he weren't, he would have known to wait.
The idea in CBT is to learn to recognize those negative thoughts and find a healthier way to view the situation. The ultimate goal is to discover the underlying assumptions out of which those thoughts arise and evaluate them. Once the inaccuracy of the assumption becomes evident, the patient can replace that perspective with a more accurate one.
Between sessions, the patient may be asked to monitor and write down the negative thoughts in a journal and to evaluate the situation that called them up. The real goal is for the patient to learn how to do this on his or her own.
What Is Behavioral Activation?
Behavioral activation is another goal of CBT that aims to help patients engage more often in enjoyable activities and develop or enhance problem-solving skills.
Inertia is a major problem for people with depression. One major symptom of depression is loss of interest in things that were once found enjoyable. A person with depression stops doing things because he or she thinks it's not worth the effort. But this only deepens the depression.
In CBT, the therapist helps the patient schedule enjoyable experiences, often with other people who can reinforce the enjoyment. Part of the process is looking at obstacles to taking part in that experience and deciding how to get past those obstacles by breaking the process down into smaller steps.
Patients are encouraged to keep a record of the experience, noting how he or she felt and what the specific circumstances were. If it didn't go as planned, the patient is encouraged to explore why and what might be done to change it. By taking action that moves toward a positive solution and goal, the patient moves farther from the paralyzing inaction that locks him or her inside the depression.
Is There a Standard Procedure for Therapy Sessions?
Mental health professionals who practice CBT receive special training and follow a manual in their own practice. Although actual sessions may vary, they typically follow this outline:
- The session begins with a check on the patient's mood and symptoms.
- Together, the patient and therapist set an agenda for the meeting.
- Once the agenda is set, they revisit the previous session so they can bridge to the new one.
- The therapist and patient review the homework assignment and discuss problems and successes.
- Next they turn to the issues on the agenda, which may or may not all get addressed.
- New homework is set.
- The session ends with the therapist summarizing the session and getting feedback from the patient.
A typical session lasts 50 minutes to an hour.
What Does It Mean to Say That Cognitive Behavioral Therapy Is Time-Limited?
Some other types of therapy are open ended in that there is no clear end date established. With CBT, the goal is to terminate therapy at a certain point, usually after 14 to 16 weeks.
It takes about eight weeks for the patient to become competent at the skills that are being taught in therapy and to reasonably understand the model. While this is going on, the patient usually experiences a significant reduction of symptoms. Between eight and 12 weeks patients often experience a remission of symptoms. During the remaining time, they continue to practice the skills learned and to address issues related to ending the sessions.
More severe cases of depression may take longer to resolve. For most patients, though, 14 to 16 weeks with occasional sessions during the first year to reinforce the new skills is adequate. "Booster" sessions are sometimes recommended to help reduce the risk for relapse and provide "refreshers" for making use of core CBT skills.