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Introduction
This Essay aims to critically compare and contrast the Behavioural Therapy and Cognitive Therapy models for treating clinical depression. I will be focusing on the theories that underline each model, their specific treatment methods, and their effectiveness.
I will start by describing depression, and give a brief summary of how depression impacts our society worldwide and how is being assessed and measured in IAPT services. Next, I will critically evaluate the literature available with regards to Behavioural Therapy and Cognitive Therapy for treating clinical depression, comparing and contrasting them from a theoretical, treatment methods and effectiveness perspective.
At the conclusion of this essay, I will summarise my findings.
What is depression, definition and context
World Health Organisation (2021) reports that depression affects 265 million people worldwide and is constantly affecting more and more people (WHO, 2021). For instance, GBD (2017) reported that between 1990 and 2007 depression disorder increased by 33.4%, becoming the third leading cause of disability. In 2013 depression took the second place as the leading cause of years lived with a disability worldwide and first place as a leading driver of disability in 26 countries. In the UK, General Health Questionnaire (GHQ-12) reports an increase in depressive cases of 1.5% between 2013 – 2014.
When talking about depression in a clinical context, it is important to make the distinction between sadness and clinical depression. Sadness is a normal reaction to loss and various other life disappointments, short-lived and, from which people tend to recover naturally. People experiencing sadness still find pleasure and interest in pleasurable activities. Clinical depression is defined as a major depressive episode that is categorized as a mood disorder or mental illness.
Another distinction worth mentioning from a causality and theoretical point of view is between endogenous depression, caused by internal factors, biological and genetic in nature, and exogenous depression (reactive or neurotic), caused by stressful life
To receive a diagnosis of clinical depression a person must present with five or more symptoms outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which must include low mood and loss of interest or pleasure in activities, manifested for more than two weeks and which were present most of the day or nearly every day. These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and must not be justified by the physiological effects of a substance or another medical condition (American Psychological Association, 2013).
To treat depression in a clinical setting, in addition to a valid diagnosis method, clinicians need reliable tools to measure its severity and manage depression-associated risks and therapeutic progress. Two models were widely researched, Beck’s Depression Inventory II (BDI II) and The Patient Health Questionnaire (PHQ-9). Both tools were assessed as having good psychometric properties. PHQ-9 proved to have a few advantages over the BDI II such as being free, shorter (only 9 items in comparison with BDI II which has 21) and it is based on DSM-5 (Titov et al, 2011).
The National Institute for Health and Care (NICE, 2009) promotes Cognitive Behavioural Therapy as a psychological intervention for treating major depressive episodes.
Behavioral Theories and Cognitive Theories approaches to understanding and treating depression
Behavioral theories attribute depression to the manner in which we interact with the environment. Behavioral theories explore our adaptive learnings and behaviors through social learning theories (Bandura, 1969) and classical and operant conditioning (Pavlov, 1927, Wolpe, 1958 Skinner, 1953, 1974).
Skinner (1953, 19740), Beck (1967), Ferster (1973), and Lewinsohn (1974) have been highly influential in the development of the two behavioral models of treating depression, Behavioural Activation Martell et al. (2001) and Brief Behavioural Activation Treatment for Depression (Lejuez et al (2001, 2002).
Behavioural Activation (BA) targets changes in environment and behavior as a method for improving mood, thoughts, and the overall quality of life. It works on the premise that negative thoughts and feelings will change once positive events and consequences are experienced more frequently.
BA aims to address at least two major depression traits, lower frequency of positive reinforcement and the increase of negative reinforcement, (Ferster, 1973), which is understood as avoidance behavior and lack of motivation, seen as a deficit of self-reinforcement and excess of self-criticism (Rehm, 1977). The therapist’s role in BA is to support the client in alleviating the depression symptoms by engaging in activities they find pleasurable and productive. The client’s environment is acknowledged as playing an important role in facilitating opportunities for positive reinforcement activities (Fester, 1973).
The therapy starts by helping the client to identify behavioral patterns related to depression. The aim is to identify these coping strategies in response to the depressed mood which in the short term may appear as beneficial, however, in the long term they maintain the vicious cycle of depression. In order to do this, the therapist needs to understand the basics of the ABC model, Antecedents, Behaviour, and Consequences. For instance, one of my clients feels overwhelmed by the amount of household chores, after the children left for school (antecedents). To cope with these feelings she usually sits on the sofa, eats something nice, and watches TV (behavior). When the children are just about to return home from school she feels guilty and useless for not doing anything around the house (consequences). The therapist’s role is to construct a formulation, identifying the behaviors responsible for maintaining the dysphoric mood and understanding the function of these behaviors. Person and Davidson (2001) defined case formulation as a systematic process for developing a hypothesis (formulation) about the mechanisms responsible for the client’s problems which shapes the basis of a treatment plan. A case formulation for a particular psychological disorder is known as a prototype formulation.
An important initial step in delivering the BA treatment protocol for depression is to support the client in identifying clear therapeutic goals based on the client’s specific life circumstances and values. Martell et al (2010) highlight the importance of understanding the client’s goals and values in designing the BA therapeutic goals. The assumption is that people are more likely to do things that are aligned with their life long-term goals and values.
Through Activity Monitoring and Scheduling, the therapist engages the client in a process of identifying more adaptive behaviors and reinforces these positive changes until they become habitual and the mood improves. In BA, rumination is seen and addressed in the therapeutic process as a behavior rather than focusing on its content. Clients are encouraged to focus on their sensorial experience and tasks at hand, escaping from their process of overthinking. Alongside the BA, a process of self-exploration, problem-solving skills, and increased self-efficacy takes place, helping the client regain control over her own life.
Martell et al (2010) proposed ten working principles that underpin the BA protocol: 1. Changing what the clients do will change the way they feel; 2. Changes in life may lead to depression and short-term coping strategies may keep people in long term; 3. The clues in finding the antidepressant behaviors lie in what precedes and follows the client’s coping behaviors; 4. Structure and schedule activities that follow a plan and not a mood; 5. Make change easier by starting small; 6. Focus on activities that are naturally reinforcing in the client’s environment; 7. The therapist acts as a coach to empower clients and promote self-efficacy; 8. BA is highly practical and focuses on problem-solving through an empirical approach; 9. BA is action-orientated, not just a talking therapy; 10. Takes into consideration possible and actual barriers to activation.
Hopko et al (2003) propose a course of 8-10 BA sessions to treat patients with clinical depression while Martell et al (2010) suggest a maximum of 24 sessions.
Cognitive Theories of Depression and Cognitive Therapy (CT)
The core idea behind all cognitive theories is that our emotional reactions and behaviors are influenced by our cognition. The goal of CT is to help clients learn how to modify their thinking to be more accurate in order to change their emotions and behaviors.
Beck took inspiration from Freud’s idea of loss and our sensibility to loss and developed the cognitive model of depression (McLeod, 2015). Beck attributes the causes of depression to negative biases and routines in our cognitive processes. Beck’s cognitive model for depression treatment acknowledges the role our early life experiences play in how we form personal views (schemas) about self, the world, and the future. This is known as Beck’s cognitive triad. In Beck’s view, the way we interpret and internalize our early life experiences affects our own evaluation of self, (lovable vs unlovable), the world (friendly vs unfriendly, accepting vs rejecting), and the future (hopeful vs hopeless) (Beck, 1967).
Beck’s view was that our early life negative experiences lead us to develop maladaptive schemas (core beliefs), consequently increasing our cognitive vulnerabilities to developing depression (Beck, 1967). The core beliefs are the most fundamental level of belief, they are global, very rigid, and overgeneralized. They lay dormant in our subconscious mind until they get activated by stressful events in our lives. The core beliefs beliefs influence the development of an intermediate class of beliefs, which consists of (often unarticulated) attitudes, rules, and assumptions.
As the core beliefs are rigid and hard to change, Beck’s CT model focuses on identifying patterns in the depressed client’s faulty thinking which derives from the client’s core beliefs, and negative automatic thoughts (NATs). The NATs could be thoughts, words, and images that go through the client’s mind which are situation-specific and are responsible for maintaining the dysphoric symptoms.
Some may argue about the importance of these maladaptive schemas in people’s cognitive vulnerability, the therapeutic process, and the therapeutic outcomes of depression. Firstly, there are other depression vulnerabilities to consider in addition to cognitive vulnerabilities such as biological vulnerabilities mentioned at the beginning of this paper. Secondly, some comparative studies between CBT and Counselling (structured vs unstructured approach) show no real differences in the treatment outcomes (Pybis et al, 2017) (King et al, 2013) which raised the question of which is the most cost-effective pathway to treat people with depression. Thirdly, Poote (2013) in her doctorate thesis concluded that her literature review found no sufficient evidence to confirm or infirm the role of early maladaptive schemas in either depressive symptoms or major depressive disorder.
In CT, the client is supported to identify the distorted cognition responsible for the dysphoric mood. Through the use of cognitive restructuring strategies, the therapist helps the client to check the validity of these NATs and replace them with more realistic thoughts. The skills of identifying, evaluating, and exploring alternative ways of thinking are being passed through the therapeutic process from the therapist to the client. This presents two advantages, helping the client improve the dysphoric mood and developing skills to minimize the risk of relapsing.
Beck’s CT model is well structured and time-limited, with 10 – 20 sessions, depending on the severity of the symptoms, the client’s circumstances, and formulation. The treatment is based on 14 principles as described by Judith Beck (2021): 1. the treatment plan is based on fluid, continuous cognitive conceptualization; 2. sound therapeutic relationship; 3. ongoing progress monitoring; 4. Culturally adapted; 5. emphasizes the positives; 6. collaboration and active participation; 7. is an aspirational, process-based, and goal-orientated process; 8. Initially focus is on the now; 9. education and therapeutic at the same time; 10. Is time limited; 11. well structured; 12. Used guided discovery and tackles dysfunctional cognition; 13. Is actively involving the client in homework activities; 14. Uses a wide variety of techniques to change thinking, mood, and behavior.
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