Depression (AQA A-Level Psychology): Revision Notes
Cognitive Treatments of Depression
Cognitive treatments of depression focus on changing negative and irrational thought patterns that contribute to depressive symptoms. These therapies are based on the cognitive model, which suggests that depression stems from maladaptive thinking processes rather than external circumstances alone.
The cognitive approach represents a fundamental shift from treating symptoms to addressing the underlying thought processes that maintain depressive episodes.
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is the primary psychological treatment for depression. It operates on the principle that our beliefs, expectations, and cognitive assessments affect how we perceive ourselves, others, and personal problems. The therapy aims to help individuals identify and modify irrational thoughts and maladaptive behaviours.
CBT views behaviour as being generated by thinking, making the most logical approach to change maladaptive behaviour through altering the underlying thought processes. The therapy recognises that thoughts directly influence emotions and behaviour, so by modifying thoughts, depressive symptoms can be reduced.
CBT operates on the core principle that changing how we think can directly change how we feel and behave, making it a powerful intervention for breaking the cycle of depression.
CBT serves as an umbrella term encompassing several specific therapeutic approaches, with the two most prominent being rational emotive behaviour therapy (REBT) and treatment of negative automatic thoughts (TNAT). Both approaches share the central goal of challenging and restructuring maladaptive thinking patterns into more adaptive, rational ones.
Rational emotive behaviour therapy (REBT)
Rational emotive behaviour therapy (REBT) was developed by Albert Ellis and refined over many years until his death in 2007. Ellis believed that "people are not disturbed by things but rather by their view of things," emphasising that emotional distress largely stems from how individuals interpret events rather than the events themselves.
Ellis identified that irrational thoughts cause emotional distress and behavioural disorders. He recognised certain musturbatory beliefs that are emotionally damaging and can lead to psychological problems. Examples include "I must be loved by everybody... otherwise everyone hates me" and "I must be excellent in all respects... otherwise I am worthless."
Musturbatory beliefs are characterised by absolute demands on oneself, others, or the world, typically expressed through words like "must," "should," or "have to." These rigid thinking patterns create unrealistic expectations that inevitably lead to emotional distress.
The ABC model
REBT employs the ABC model as a central technique for understanding and recording the relationship between events, thoughts, and consequences:
Worked Example: The ABC Model in Practice
A = Activating event: Patients identify and record events that trigger disordered thinking, such as failing an exam
B = Beliefs: Patients examine the negative thoughts associated with the event, such as "I'm useless and stupid"
C = Consequence: Patients note the negative thoughts or behaviours that follow, such as feeling upset and considering leaving college
The reframing process
REBT involves reframing, which means challenging negative thoughts by reinterpreting the ABC model in a more positive and logical manner. For example, if an exam was difficult or there wasn't sufficient time for revision, the therapist helps the patient see this more optimistically rather than catastrophically.
The treatment process typically involves one or two therapy sessions every two weeks for approximately fifteen sessions. Therapists and patients collaborate to verify reality through examining evidence. When a patient makes negative statements like "I'm a poor parent because my children misbehave," the therapist guides them to assess the truth of this belief, helping them recognise that children sometimes misbehave regardless of parenting quality.
Treatment phases and techniques
CBT treatment follows a structured approach with distinct phases that build upon each other to create lasting change:
Education phase: Individuals learn about the relationships between thoughts, emotions, and behaviour. This foundational understanding prepares them for active participation in changing their thought patterns.
Behavioural activation and pleasant event scheduling: These techniques aim to increase physiological activity and participation in social and rewarding activities. This approach addresses the tendency for depressed individuals to withdraw socially and reduces their engagement in enjoyable activities.
Cognitive restructuring: After patients experience improvements in mood or energy, cognitive factors are addressed. Patients learn to identify faulty thinking patterns responsible for low mood and develop skills to challenge these thoughts.
Hypothesis testing: Between sessions, patients receive goals to boost self-esteem through behavioural coping skills. This involves testing negative thoughts through real-world experiences. For instance, patients might test beliefs about social rejection by engaging with strangers in social situations. Therapists set achievable tasks to build confidence, as failure would reinforce feelings of inadequacy.
Relapse prevention: A few booster sessions are provided in the subsequent year to prevent symptom recurrence and maintain therapeutic gains.
Each phase builds systematically on the previous one, creating a comprehensive treatment approach that addresses both immediate symptoms and long-term maintenance of mental health improvements.
Contemporary research evidence
Embling (2002) - The effectiveness of cognitive behavioural therapy in depression
This landmark study provided crucial evidence for CBT's effectiveness in treating depression through a well-controlled research design.
Participants: An opportunity sample of 38 patients aged 19-45 years suffering from depression, diagnosed using ICD-10 criteria
Aim: To assess which types of depressive patients benefit most from CBT and to explore the relationship between emotions and depression
Procedure:
- Participants were divided into treatment and control groups
- The waiting list control group (19 patients) received antidepressant medication and brief clinical consultations
- The treatment group received 12 sessions of CBT from trained therapists, with sessions lasting 60-90 minutes
- Both groups continued receiving drug therapy throughout the study
- Participants used dysfunctional thought records (DTRs) to monitor mood changes
- The Beck Depression Inventory version 2 (BDI-II) assessed depression levels before, during, and after treatment
The use of dysfunctional thought records (DTRs) allowed patients to track their progress in real-time, providing valuable data about the relationship between thoughts and mood changes throughout treatment.
Findings:
- Treatment group showed significant decreases in BDI-II scores over the course of treatment, while control group scores remained unchanged
- Treatment group participants expressed more negative emotions initially but showed improvement over time
- Patients who didn't improve with CBT had high levels of sociotropy (need for approval from others) and perfectionism, along with low autonomy and high external locus of control
Conclusions:
- Depressed patients are less likely to readily express negative emotions
- CBT combined with drug therapy proves more effective than drug therapy alone
- Personality characteristics influence CBT outcomes, with perfectionist traits and external locus of control associated with poorer treatment response
Supporting research evidence
The effectiveness of CBT has been consistently demonstrated across multiple independent studies, strengthening the evidence base for its clinical application.
Lincoln et al. (1997) identified stroke victims who developed clinical depression and provided CBT sessions for four months, resulting in reduced symptoms and suggesting CBT's suitability for specific depression types.
Department of Health (2001) reviewed various depression treatments and found CBT to be most effective, though didn't endorse CBT alone as other treatments like behavioural therapy also showed effectiveness.
Whitfield & Williams (2003) found CBT had the strongest research foundation for effectiveness but noted delivery challenges in the National Health Service. They suggested self-help versions like the SPIRIT course could address accessibility issues.
The accessibility challenges identified by Whitfield & Williams highlight an important consideration: even highly effective treatments must be deliverable within existing healthcare systems to benefit patients.
Hollon et al. (2006) discovered that 40% of moderately to severely depressed patients treated with CBT for sixteen weeks relapsed within twelve months, compared to 45% for drug therapy patients and 80% for placebo patients, indicating CBT's slight superiority over medication long-term.
David et al. (2008) found that patients with major depressive disorder treated with fourteen weeks of REBT showed better treatment outcomes than those receiving fluoxetine six months post-treatment, supporting REBT's long-term effectiveness over drug therapy.
Evaluation of cognitive treatments
Strengths
The evidence base for cognitive treatments reveals several significant advantages that make them particularly valuable in clinical practice.
High effectiveness: CBT represents the most effective psychological treatment for moderate and severe depression, particularly when depression is the primary concern. It also effectively prevents mild depression from progressing to severe depression and has minimal side effects compared to drug treatments.
Quality training matters: Better-trained therapists consistently achieve superior therapeutic outcomes, highlighting the importance of proper professional development in treatment effectiveness.
The quality of therapist training directly impacts treatment outcomes, making professional development and ongoing supervision crucial elements of effective CBT delivery.
Cost-effective and efficient: CBT applications occur over relatively short time periods compared to other treatments and demonstrate cost-effectiveness. The therapy also provides long-term benefits, as patients continue using learned techniques to prevent symptom recurrence.
Rapid improvement: CBT can produce condition improvements very quickly, while drug treatments typically require 10-14 days to show effects, making it easier to encourage patient compliance.
Weaknesses
Despite its strengths, cognitive treatments face several important limitations that must be considered in clinical decision-making.
Causation uncertainty: One significant concern involves whether disordered thinking causes depression or results from it. Many cognitive behavioural therapists acknowledge this relationship likely works bidirectionally.
The chicken-and-egg question of whether negative thinking causes depression or depression causes negative thinking remains unresolved, which has important implications for understanding how CBT works.
Therapist dependency: CBT can become overly therapist-centred, with therapists potentially abusing their control over patients by directing them towards specific thinking patterns. This can create unhealthy dependency relationships between patients and therapists.
Assessment challenges: CBT proves difficult to evaluate systematically. Different measurement scales produce varying improvement measures among patients, making objective assessment problematic.
Limited applicability: For patients with concentration difficulties, CBT can feel unstable and overwhelming, potentially strengthening depressive symptoms rather than alleviating them. Additionally, CBT isn't suitable for patients who struggle discussing inner feelings or lack verbal communication skills.
Mixed research outcomes: While some studies demonstrate CBT's effectiveness, others show more modest benefits, and drug therapies have shown improvements that sometimes challenge CBT's superiority claims.
Key Points to Remember:
- CBT is the primary psychological treatment for depression, focusing on changing negative thought patterns rather than just symptoms
- The ABC model (Activating event → Beliefs → Consequences) helps patients understand how their interpretations of events influence their emotional responses
- REBT challenges "musturbatory beliefs" that create unrealistic expectations and emotional distress
- Research evidence strongly supports CBT's effectiveness, particularly when combined with medication and delivered by well-trained therapists
- CBT has limitations including potential therapist dependency, unsuitability for some patients, and questions about whether it addresses causes or symptoms of depression