Psychology and depression: cognitive-behavioral treatment

“Mr. Rodrigo enters my psychology consultation. He tells me that he has not wanted to live for a long time: he has been sad for a long time, that he does not feel like doing anything or sees anything that could make him the least illusion. Even things that you were passionate about before are now only a mere hindrance. In addition to this, he indicates that he does not see that the situation is going to improve at any time, having considered being a hindrance to his loved ones.

These at first were good with him, but over time they ended up getting tired, and now he is alone. As far as he refers, together with the results obtained from the various tests and evaluation measures that I apply to him, everything suggests that we are dealing with a case of major depressive disorder. However, now is the time to ask myself, what can I do as a professional to help him improve his situation?

Analyzing the case: depression

Depression. This word is commonly used, in everyday language, to refer to a sad state

that remains for a time interval. However, this use of the concept in common language misses much of what the term implies at the clinical level.

Clinically, the presence of a major depressive disorder is considered to be the presence for at least two consecutive weeks of depressive episodes, which are defined by the presence of five symptoms, one of them being a sad mood and / or the presence of apathy (lack of motivation / interest) or anhedonia (lack of pleasure). Other symptoms include appetite / weight changes, fatigue, agitation or sluggishness, guilt and thoughts of suicide. To be considered as such, it must interfere with daily life and not be due to other disorders, such as psychotic ones. It is one of the most frequent mood disorders in the population.

Although these are the typical symptoms of depression, it is worth asking: how to interpret and treat it?

Treating depression

There are numerous models that attempt to explain the depressive process and its causes. This wide diversity fortunately means that a large number of techniques are available to treat depression. One of the known, successful and used today comes from the Beck's Cognitive Theory.

Beck's cognitive model

This theory considers that the elements that are most important in depression are cognitive. According to this theory, the main problem of depressed subjects is cognitive distortion when it comes to interpret the phenomena of reality, focusing attention on knowledge schemes consistent with our cognitions. Due to these patterns and distortions, we have negative thoughts about our own self, the future that awaits us and the world around us (thoughts known as the cognitive triad).

Based on this theory, Beck himself designed cognitive therapy to treat depression (although it has subsequently been adapted to other disorders).

Beck's cognitive therapy for depression

This therapy has been developed in order for patients to discover more positive ways of interpreting reality, moving away from the depresogenic schemes and the cognitive distortions typical of depression.

It is intended to act from a collaborative empiricism in which the patient actively participates in creating situations that allow him to do behavioral experiments (that is, testing his beliefs), which will be proposed between the therapist and the self patient. Likewise, the psychologist will not confront dysfunctional beliefs directly, but will favor a space for reflection for the patient, so that ultimately it is he who sees the inaccuracy of his beliefs (this way of proceeding is known as the method Socratic).

To act in this area, we will work both from cognitive, behavioral and emotional techniques.

Behavioral techniques

These types of techniques are intended alleviate lack of motivation and eliminate the passivity of depressed patients. In the same way, they also allow to test their own beliefs of guilt and worthlessness, their basic operation being the performance of behavioral experiments.

1. Graded Homework Assignment

It is based on the negotiation of the performance of various tasks, graded according to their difficulty, so that the patient can test her beliefs and increase your self-concept. Tasks must be simple and divisible, with a high probability of success. Before and after performing them, the patient has to record her expectations and results, in order to contrast them later.

2. Activity program

The activities that the patient will do, including schedule. It is intended to force the elimination of passivity and apathy.

3. Use of pleasant activities

Thought to eliminate anhedonia, It is about doing activities that are or will be rewarding, proposing them as an experiment and trying to monitor the self-fulfilling prophecy effect (That is, there is no failure because the belief that it is going to fail induces it). To be considered successful, it is enough that there is a decrease in the level of sadness.

4. Cognitive essay

This technique has great relevance. In her the patient is asked to imagine an action and all the steps required to complete it, indicating possible difficulties and negative thoughts that could interrupt it. Likewise, it seeks to generate and anticipate solutions to these possible difficulties.

Cognitive techniques

These types of techniques are used in the field of depression with the aim of detect dysfunctional cognitions and replace them with more adaptive ones. Some of the most used cognitive techniques are the following:

1. Three column technique

This technique is based on a self-registration by the patient, indicating in a daily record the negative thought he has had, the distortion committed and at least one alternative interpretation to the thought of him. Over time they can become more complex tables.

2. Down Arrow Technique

This time it is intended to go deeper and deeper into the patient's beliefs, bringing to light the deepening beliefs that provoke negative thoughts. That is to say, it begins from an initial affirmation / thought, and then to see what makes you believe such a thing, then why is this second idea thought, and so on, seeking an increasingly personal meaning and deep.

3. Reality tests

The patient is asked to imagine his perspective of reality as a hypothesis to be tested, to later design and plan activities that can contrast it. After conducting the behavioral experiment, the results are evaluated and the initial belief is worked on to modify it.

4. Expectations record

A fundamental element in many of the behavioral techniques **, it is intended to contrast the differences between initial expectations and actual results ** of behavioral experiments.

Emotional techniques

These techniques seek to reduce the negative emotional state of the patient through management strategies, dramatization or distraction.

An example of this type of technique is time projection. It is intended to project into the future and imagine an intense emotional situation, as well as the way to face and overcome it.

Structuring the therapy

Cognitive therapy for depression It was proposed as a treatment to be applied between 15 and 20 sessions, although it can be shortened or lengthened depending on the needs of the patient and the evolution of it.

A therapy sequencing should first go through a previous evaluation, and then move on to the carrying out cognitive and behavioral interventions and finally contributing to modify the schemes dysfunctional. A possible phasing sequence could look like the following:

Phase 1: Contact

This session is mainly dedicated to collecting patient information and her situation. Likewise, it seeks to generate a good therapeutic relationship that allows the patient to express himself freely.

Phase 2: Start intervention

The procedures to be used throughout the treatment are explained and the problems are organized so that the most urgent is worked first (therapy is structured differently, for example, if there is a risk of suicide). Expectations regarding therapy are worked on. The psychologist will try to visualize the presence of distortions in speech, as well as elements that contribute to maintaining or resolving depression. Self-registrations are made.

Phase 3: Performing techniques

The performance of activities and behavioral techniques described above is proposed. Cognitive distortions are worked with cognitive techniques, considering the need for behavioral experiments.

Phase 4: Cognitive and behavioral work

The cognitive distortions from the experience obtained from the behavioral experiments and the contrast of the self-records with respect to the real performance.

Phase 5: Reattribution of responsibility

The responsibility of setting the agenda to the patient begins to be delegated each time, increasing their level of responsibility and autonomy, exercising the supervisory therapist.

Phase 6: Preparation for completion of therapy

The continuation of the strategies used in therapy is encouraged and strengthened. Little by little the patient is prepared so that he can identify possible problems on his own and prevent relapses. The patient is also prepared for the completion of therapy. The therapy is finished.

Bibliographic references:

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. DSM-V. Masson, Barcelona.

• Beck, A.T. (1976). Cognitive therapy and the emotional disorders. International University Press, New York.

• Belloch, A.; Sandín, and Ramos (2008). Manual of psychopathology. Madrid. McGraw-Hill (vol. 1 and 2). Revised edition.

• Santos, J.L.; García, L.I.; Calderón, M.A.; Sanz, L.J.; de los Ríos, P.; Izquierdo, S.; Roman, P.; Hernangómez, L.; Navas, E.; Ladrón, A and Álvarez-Cienfuegos, L. (2012). Clinical psychology. CEDE PIR Preparation Manual, 02. CEDE. Madrid.