CBT and Depression
by Gemma Lutwyche
What is depression?
The term depression comes from the Latin ‘deprimere’ which means to ‘press down’. It is far more, however, than just feeling down and affects not only how we feel but how we think about things, our concentration, sleep, energy levels and interest in hobbies, for instance.
Officially, the symptoms of depression are the following:
- Low mood
-Marked loss of pleasure
Plus 4 of the following:
- Significant change in appetite and a loss of 5% of body weight
- Disturbed sleep
- Agitation or feeling of being slowed down
- Loss of energy every day
- Feeling worthless, having low self esteem and feeling guilty
- Loss of ability to concentrate
- Thoughts of suicide
There are different types of depression but whichever you are experiencing it is likely that it will be very disturbing to your life.
What causes depression?
Sometimes depression results from something that has been ‘turned on’ in us. Some aspects of depression seem to relate to mechanisms that evolved a long time ago, for instance coping with the loss of a loved one, being subordinated, defeated or trapped.
How can CBT help with depression?
CBT (cognitive behaviour therapy) can help on various levels with depression.
If we think about the different parts of the CBT model, which outlines that a human function is made up of thoughts, feelings, behaviours and physical sensations. In treating depression it is helpful to think of each of these in turn.
Looking at physical reactions – breathing and relaxation
As depression is often related to an overloading of the stress system, and excessive cortisol, it can be helpful as part of therapy to start to get this under better control.
Ways of doing this can include breathing exercises (please see ‘Breath Work’ in this series), and relaxation strategies, so that you can start to become more aware of your stress and have some control over your bodily reactions.
At this early stage it can also be good to start looking at strategies to stay in the moment, such as mindfulness, which help to add to the feeling of being in control and help to prevent the mind wandering into a negative spiral, which can bring in the physical symptoms of stress.
Changing behaviours – encouraging activity
When someone is depressed they often feel that they have no energy, or that they have lost excitement for things they once used to do. It can be the case that they may be at work and functioning, and just stopped doing their hobbies. Or their depression could be more severe and they could find that they cannot even get up, shower and brush their teeth.
One initial step is therefore to look at the amount of physical activity they are doing in a day, and try to increase it, with ‘activity scheduling’. This helps to reduce low mood on the basis that if someone is giving in to the low mood and not doing anything, the more they do that - the more depressed they are likely to feel. So, if they are able to do the opposite, and engage in activity, this should improve their mood. You may then in therapy devise a weekly schedule of things you will try to do, based on your current functioning.
At some stage of therapy it can be helpful to introduce behavioural experiments, which look at helping you to tackle some of the situations which your depression is making difficult for you. For instance, if you used to like playing tennis, and have felt unable to go because of your mood, it could be that in therapy you design an experiment to go and visit the tennis court, or go with a friend and just play for a few minutes, as an initial step. Later experiments could help to build on this, encouraging you to be able to stay for longer, until you are able to return to your original activity. The experiment would support you as well, by helping to think about any barriers that might get in the way, and what help you might need.
Managing difficult thoughts and feelings
People with depression tend to have a negative thought pattern, which involves negative thoughts about themselves, the world and their future. CBT can help by initially using diaries to track the ‘automatic thoughts’ which come into your mind, for instance, ‘I can never do things right’ or ‘No one likes me’. Being able to be aware of these thoughts is a helpful first step to being able to change them. Sometimes, if you are aware of a change in your mood, that can help to alert you to what is going on in your mind.
Challenging thoughts, and showing compassion
The next step, once you are able to identify your thoughts in a particular situation, is to start thinking about how you can answer those thoughts back. For instance, if you were waiting for a friend to call and they don’t, and then you find yourself thinking ‘no-one cares about me’, then you can start to unpick this and assess the reality of this. Is there an alternative explanation, and what might that be? The friend may have been busy, could be unwell and therefore no deliberately trying to avoid you, for instance. It can also be good at this stage to start to develop feelings of compassion towards yourself, and to say, what would someone who cares about me think right now? How can I be kinder to myself in this situation?
Understanding the patterns of your thinking
Once you have spent some time assessing your thoughts, it can be good to start identifying the patterns in your thinking. We often find that people have a tendency towards particular patterns such as overgeneralising, for instance when something goes wrong, saying to yourself, ‘everything in my life ends badly’. Another common pattern is people jumping to conclusions for instance if you were not invited to a friend’s party, assuming that you have upset them, without waiting to find out what happened. These patterns can be helpful to understand, as they show us the ‘rules for living’ that we have identified for ourselves, which can often not serve us well.
Looking at core beliefs
In therapy, the process of looking at thought patterns and thinking errors can allow you to identify the core beliefs that you have about yourself which are likely to be driving your behaviour. For instance, you might identify that you often have thoughts around being accepted by others, and you may have the underlying belief that you are not loveable. You might alternatively have thoughts about your worth, and assume that you will fail at things and therefore it is not worth trying; ‘I’m a failure’ or ‘I’m not good enough’. Sometimes it can be helpful to explore the origins of these beliefs, but it can also be helpful to look at ways to show exceptions to these ways of looking at yourself. For instance, in the example of not being good enough, you might monitor times when you do feel good enough, and also think about ways in which you were good enough in the past. The depressed brain state can make these beliefs hard to access without the right support.
(This is a fictitious example for the purpose of illustration only)
Angela was in her early forties, she had been feeling depressed for a few months following the end of her marriage. She found that she was frequently irritable, and wanted to escape from her children who were 6 and 3 years old respectively. She felt guilty about wanting to be away from them but irritated by them as well, which meant she was often short tempered. She had had to take some time off work as she felt unable to concentrate, and at times her mood dipped to the point where she was feeling suicidal. She felt tired most of the time, but was also having problems sleeping at night. She found herself withdrawing from her friends, and also stopped going to the gym as she felt she lacked the energy. In Angela’s case, her depression was triggered by the loss of a loved one (her spouse, with the end of the relationship) and she felt trapped in her role as a single parent.
Therapy for Angela started by looking at how to help her to gain some control of her stressful reactions through the use of relaxation and breathing techniques. She also started using mindfulness (please see ‘Controlling Unhelpful Thoughts’ in this series) to help her stay focused on times when she was with her children, and not get distracted by her depressed mood. She reported finding that focusing on the present, through the mindfulness strategies also helped her to stay in the moment, and take one day at a time, and not become preoccupied with uncertainty around her future due to her changed circumstances.
Her therapist helped her to start building more activity into her week, including taking the children to activities, and helping her to attend work again. Getting back to the gym was more difficult as she was feeling a lack of confidence from the marriage break up, and she was given the homework task of trying to go first to the entrance, and then to the changing room, before going to a 20 minute session and then being able to get back to a class. She was feeling that others would ask where she had been and she would feel self-conscious. In therapy she discussed what she could say in those situations, but once she returned there she found that she was welcomed and that people had missed her.
Angela got into the habit of tracking her thoughts, and found that she was often feeling hopeless about the future, that she was ugly and no-one liked her. She gradually started to challenge these thoughts, as her mood improved, so that she could realise that she still had goals and things to look forward to, and her taking care of herself better helped her feel better about herself generally. She started to try and challenge the beliefs around her not being good enough, by being kinder to herself and more realistic about her expectations.