Depression and Cognitive Behavioural Therapy

by Chris Williams and Ben Wiffen

Read: Depression and Cognitive Behavioural Therapy (Part 1)

CBT is a Primary Treatment Option
Whilst individuals may feel like there is no hope, some interventions have been shown to be effective for depression. Medication, most commonly Selective Serotonin Reuptake inhibitors (SSRIs), can be particularly effective for more severe episodes of depression, although the evidence base for milder depression is less clear.7

Over recent years, there has been an increasingly strong body of evidence for a range of psychological interventions to help treat depression, as well as a number of anxiety disorders.8,9 The most widely evaluated of these is Cognitive Behavioural Therapy (CBT). CBT is most commonly conducted in weekly therapy sessions one-to-one over a period of weeks or months depending on the nature of the problem and proposed intervention.

The cognitive model of depression10 is based on the rationale that an individual’s mood and behaviour are determined by the way in which they interpret the world around them. Central to this is the understanding that it isn’t events themselves that cause depression, but how a person interprets those events. Accordingly, the most effective means of intervening is to identify and challenge inaccurate thoughts that lead to unpleasant feelings and unhelpful behaviours.

CBT uses a structured approach, rather than simply providing space for the patient to talk about their problems at great length. It tends to focus on an individual’s current experience and difficulties, as well as how lessons from the past affect them today. A collaborative approach is adopted, where the therapist and patient work together as equals with different strengths. This is used to help the patient recognise connections between their thoughts, feelings and behaviour so they can work out together why they feel as they do. The therapy then moves on to teach specific strategies to help identify and change upsetting thinking, face bears, build confidence, and learn skills of problem solving that can be used in everyday life such as addressing an issue with a neighbour, or planning a response to a difficult colleague.

Does CBT Work?
Many randomised controlled trials have shown CBT to be effective in reducing symptoms and improving quality of life across a range of conditions including depression. Consequently, NICE guidelines suggest that individuals experiencing depression should be offered CBT.11

Whilst the efficacy of CBT is clear, many people may face problems accessing CBT within the NHS. Given the large number of people who struggle with depression and anxiety, and the limited numbers of professionals equipped to provide such an intervention, there have been substantial; discrepancies between levels of supply and demand.12 This has sometimes meant long waiting lists for services, and reluctance among GPs to even make referrals for psychological interventions due to the long wait for a service. The recent development of shortened ways of delivering CBT, including the use of CBT books, classes and computer programmes has meant local mental health services have more ways of providing CBT to a greater number of people.

The CBT Model in Practice – A Five Areas Approach
One criticism that can be made of the traditional CBT approach is that the language used tends to be complex, adopting terms that not immediately understood by practitioners or patients. The Five Areas approach13 aims to provide a user-friendly and accessible for of CBT that can be easily understood.

It offers a whole-person assessment that helps the person identify problems they face in each of five areas of their life:

  1. External events – the different life situations, relationships, practical resources and problems around the person.
  2. Altered thinking with extreme and unhelpful thoughts.
  3. Altered emotions – mood or feelings such as low or anxious mood, shame, guilt and anger.
  4. Altered physical feelings/symptoms in the body such as pain or low energy
  5. Altered behaviour or activity levels such as avoidance and reduced activity.

An example of a completed Five Areas Assessment model is shown in Diagram 1 which summarises the case of a 60 year old woman who has felt anxious and depressed for the last six months. It shows that what a person thinks about a situation or problem may affect how they feel physically and emotionally, and also alters what they do (behaviour or activity). Each of there five areas affect each other.

The diagram shows that making changes in any of the areas can be helpful. Targets can be identified for change and intervention as well as providing a rationale for why Anne feels as she does. The model can summarise a range of situations and physical disease in addition to mental health problems and can incorporate faith-based relationships and church and with God.

Making Changes Using CBT
CBT brings about change predominantly by focusing on addressing three of the five areas:

External Events (Area 1) – a problem solving approach can be used to tackle external difficulties in relationships, or problems such as debt.

Altered thinking (Area 2) – for example, if someone is expecting to receive a phone call from a friend, and they do not call, they might think to themselves ‘I must have upset them’, which may lead them to feel sad or worried. An alternative, more helpful thought might be that ‘my friend must have got held up at work’, which would make them feel more relaxed or sympathetic toward their friend. CBT attempts to identify unhelpful and inaccurate thoughts and helps the person to generate more helpful alternatives, which may leave them feeling better. It also encourages the person to step back and choose not to get caught up in such unhelpful thoughts that worsen how they feel, or affect what they do.

Altered Behaviour (Area 5) – here three vicious circles are commonly targeted. They are:

a) Reduced or avoided activity
In depression, the person often struggles to maintain their activity levels because of their symptoms. They often force themselves to complete things they feel they must/should/ought to do. However, things they would usually do for themselves such as hobbies and seeing friends are often reduced or stopped completely. The result is that the worse they feel, the less they do, and the less they do the worse they feel. A vicious circle is established and slowly the person finds their life is emptied of activities that give them a sense of pleasure, achievement and closeness. This can be reversed by planning to complete activities that give a sense of pleasure, achievement or closeness to others, and are important to the person. This behavioural activation approach can be just as effective as the full CBT package for some people.14

b) Unhelpful behaviours
Activities like drinking to much, smoking, overeating, misusing medication, pushing people away and taking risks are commonly seen in depression. Such activities can be particularly distressing for Christians who find themselves acting against their faith in some way. These activities worsen how the person feels, yet are usually done because they provide a short-term relief from symptoms. CBT treatment includes recording what is being done, and identifying factors leading to it. Treatment plants focus on a slow reduction of these behaviours, whilst filling the gap with more helpful ones. To this, for Christians, can be added prayer support from local church teams, friends and other church teams, friends and other church members.

c) Helpful activities
A range of simple activities can be helpful including:

  1. Self-care – eg having a haircut or a massage
  2. Meeting friends helps the person feel closeness with others.
  3. Doing a Wow walk15 – This involves walking with someone else and Wow-ing at the amazing world around. This provides closeness, activity and choosing to focus on the positives, and for Christians can lead to praising God.
  4. Exercise – This helps prevent physical de-conditioning and boosts mood.
  5. Eating sensibly – thress regular meals a day, including breakfast.
  6. Using music to lift mood and also avoiding tracks that remind the person of sad or angry times. Praise songs and albums may be helpful for Christians.

Read more: “Using CBT with Individual Christians & How Churches can Help”
Depression and Cognitive Behavioural Therapy (Part 3-end)

Christian Medical Fellowship (CMF) Files No. 53, 2014