Psychopathology - The Cognitive Approach to explaining and treating depression

Question 1

Key definitions

Answer 1

• Depression - a mood disorder where an individual feels sad and or lacks interest in their usual activities; further characteristics include irrational negative thoughts, raised or lowered activity levels and difficulties with concentration, sleep and eating
• Cognitive approach - studies internal mental processes such as attention, perception, memory and decision-making and assumes that the mind actively processes information from our senses and learning comes from internal mental processes
• Negative triad - a cognitive approach to understanding depression, focusing on how negative expectations (schema) about the self, world and future lead to depression
• ABC model - refers to the three components of experience that can be used to judge whether an individuals belief system is distorted; A (Activating event), B (Belief) and ultimately C (consequences)

Question 2

Emotional characteristics of depression

Answer 2

• Depressive mood
• Anger directed at themselves or others (can lead to self-harming behaviours)
• Feelings of worthlessness
• Lack of interest and pleasure in daily activity

Question 3

Cognitive characteristics of depression

Answer 3

• Low concentration and difficulty or slowness responding to decisions
• Focus on the negative / negative self-esteem / absolutist thinking
• Recurring thoughts of self-harm from imbalanced neurotransmitters

Question 4

Behavioural characteristics of depression

Answer 4

• Reduction of energy / constantly feeling fatigued
• Issues with sleeping / disturbed sleep / insomnia
• Changes in appetite (over or under eating)
• Self-harm / low self-hygiene

Question 5

What is depression? + the cognitive approach to it

Answer 5

Depression is a mood disorder, characterised by low mood and low energy levels.
- The cognitive approach generally explains depression in terms of faulty and irrational thought processes and perceptions - where behaviourist explanations would generally focus on maladaptive behaviours, the cognitive approach generally focuses on maladaptive cognitions that underpin these behaviours

Question 6

Cognitive approaches to treating depression - Ellis’ ABC Model 1962

Answer 6

• Albert Ellis proposed that the key to mental disorders such as depression lay in irrational thoughts; for Ellis, irrational thoughts that interfere with us being happy and free of pain
  To explain depression, he developed the ABC Model:
• A = Activating event; Ellis focused on situations in which irrational thoughts are triggered by external events, and we get depressed when we experience negative events and these trigger irrational beliefs. The activating event is therefore the negative event, such as getting fired at work
• B = Belief; you hold a belief about the event or situation, which could be rational (e.g. the company was overstaffed), or irrational (e.g. I was sacked because they didn’t like me) - there are a range of irrational beliefs
• C = Consequence; you have an emotional response to your belief, and rational beliefs lead to healthy emotions (e.g. happiness) whereas irrational beliefs lead to unhealthy emotions (e.g. depression)

The activating event triggers an emotion that is seen as true and the consequence is that the individual becomes depressed because they have a negative view of themselves and no confidence in their ability. Other people who do not tend towards depression may react completely differently, with the difference between depressed and non-depressed people being how they perceive themselves following an event or in general.

Question 7

ABC Model - types of irrational beliefs

Answer 7

1) Mustabatory thinking - the belief we must always succeed or achieve perfection
2) Utopianism - the belief life is always meant to be fair
3) I-can’t-stand-its - the belief that it is a major disaster when something doesn’t go smoothly

An example of the ABC Model in action:

• A = your teacher tells you that she’s unhappy with your work
• B = you see yourself as a failure (irrational belief)
• C = a feeling of worthlessness (unhealthy emotion)

Question 8

Beck’s Negative Triad - 1967 (Beck’s Cognitive Theory)

Answer 8

• Beck suggested a cognitive approach to explaining why some people are more vulnerable to depression than others, and it is a person’s cognitions that create this vulnerability i.e. the way they think

Beck suggested three parts to this cognitive vulnerability:

1) Faulty information processing - when depressed, we tend to focus on the negative aspects of a situation and ignore the positives, and we also tend to blow small problems out of proportion and think in ‘black and white’ terms
2) Negative self-schemas - a schema is a package of ideas and information developed through experience, and they act as a mental framework for the interpretation of sensory information; a self-schema is a package of information we have about ourselves, and we use these to interpret the world, so if we have negative self-schema we interpret all information about ourselves in a negative way
3) The negative triad - a person develops a dysfunctional view of themselves because of the three types of negative types of thinking that occur automatically, regardless of the reality of what is happening at the time. These three elements are called the negative triad; when we are depressed, negative thoughts about ourselves, the world and the future often come at us

Question 9

Beck’s Negative Triad 1967 - elements of the negative triad vulnerability

Answer 9

• Negative view of the self - where individuals see themselves as being helpless, worthless and inadequate e.g. ‘I am just plain and undesirable, what is there to like?’ and these thoughts enhance existing depressive feelings because they confirm the existing emotions or low self-esteem
• Negative view of the world (life experiences) - where obstacles are perceived within one’s environment that cannot be dealt with e.g. ‘I can understand why people don’t like me. They would prefer someone else’s company’ and this creates the impression that there is no hope anywhere
• Negative view of the future - where personal worthlessness is seen as blocking improvements e.g. ‘i am always going to be on my own, there is nothing that will change that’ and these thoughts reduce hopelessness and enhance depression

Question 10

Practical applications of the ABC Model and the Negative Triad theory to CBT

Answer 10

• Beck – Beck’s theory forms the basis of CBT. All cognitive elements of depression (including the negative triad) can be identified and challenged in CBT. This means that a therapist can challenge them and encourage the patient to test whether they are true.
• Ellis – Ellis’ theory has led to a successful CBT. His idea that by challenging the negative, irrational beliefs a person can reduce their depression is supported by research evidence.

These are strengths of the theories because they translate well into successful therapies and suggest that negative/irrational cognitions play some role in depression.

Question 11

Evaluation of the cognitive explanations for depression - Strengths and Weaknesses

Answer 11

1) Weakness - Cognitive explanations of depression share the idea that cognitions cause depression, which is linked to the idea of cognitive primacy, suggesting that emotions are influenced by your cognitions. This is certainly the case sometimes, but not always, and other theories of depression see emotions as influencing cognitions.
- This suggests that the theories can give a good understanding of the interaction of cognitions and emotions (holistic) - but are not entirely internally valid as they do not accommodate for extraneous variables, and ignores how although cognitions have a big influence, it is not the only influence in causing depression
- Beck’s criteria is also subjective, and the approach ignores the effect of behaviour and context on depression being caused

1) Strength - Some cases of depression follow activating events. Psychologists call this reactive depression and see it as different from the kind of depression that arises without an obvious cause.
- Therefore, they are a good explanation of different types of depression and they are applicable to understanding different forms and manifestations of depression, allowing better insight into individual types and treating and understanding depression
- Provides detailed explanations of the range of way it is caused, which can help with treatment

Question 12

Evaluation of the cognitive explanations for depression - Strengths pt 2

Answer 12

2) Practical applications - provides real-world applications for the theories and have been beneficial to helping treat depression

3) A range of evidence supports the idea that depression is associated with faulty information processing, negative self-schemas and the cognitive triad of negative automatic thinking. For example, research has found that women judged to have been high in cognitive vulnerability were more likely to develop post natal-depression. Additionally, a review study concluded that there was solid support for each cognitive vulnerability factor and the cognitions could be seen before depression develops.
- This provides external validity for the theories, which give good support to the theories by evidencing the explanations for depression, particularly Beck’s triad, for how depression develops

Question 13

Evaluation of the cognitive explanations for depression - Weakness

Answer 13

1) Both explanations cannot explain all symptoms of depression. For instance, some patients are deeply angry, some suffer hallucinations, and very occasionally suffer from Cotard syndrome, the delusion that they are zombies. The explanations cannot easily explain these cases.
- This means that the explanations are not entirely generalisable to all instances of depression and are too deterministic / not applicable to individual cases of depression. They therefore lack some generalisability / applicability

Question 14

The cognitive approach to treating depression - CBT

Answer 14

• Cognitive behavioural therapy - CBT assists patients to identify irrational thoughts and change them.
• As behaviour is seen as being generated by thinking, the most logical and effective way of changing maladaptive behaviour is to change the irrational thinking underlying it.
  Therefore, CBT involves cognitive and behavioural elements:
  1) Cognitive – identifying and challenging irrational thoughts
  2) Behavioural – once irrational thoughts have been identified, coping strategies are developed (behavioural change)

Key elements of CBT:

• Identifying irrational thoughts.
• Assessment - client and therapist identify the problems and the goals - plan is put in place
• Challenging the irrational thoughts through direct questioning – disputing. This includes using evidence to contradict the client’s irrational thoughts.
• More rational thoughts leading to the effect of feeling better (overcoming depression).
• Behavioural activation - work to change unhelpful thought patterns and put more effective behaviours in place
• Will often set homework

Question 15

Different types of CBT - Beck’s Cognitive therapy

Answer 15

• This is the application of the cognitive theory - it aims to identify and challenge negative automatic thoughts surrounding the world, future and self (negative triad)

Key elements -

• Direct challenging
• Hypothesis testing / testing the reality of their beliefs -
  1) Set homework e.g. record when people are nice to you; when you enjoyed an event; received positive feedback
  2) Findings can be used in future sessions to prove the client wrong when they make an irrational statement

Question 16

Different types of CBT - Ellis’ Rational Emotive Behaviour Therapy (REBT)

Answer 16

• Works by identifying and challenging irrational thoughts to show the client how irrational their thoughts are, and replacing them with more effective and rational beliefs
• For his therapy, Ellis extended his ABC model to ABCDE where the D = Disputing and E = Effect

There are a number of ways that irrational thoughts are disputed as part of REBT, and these all involve the therapist directly questioning the client

1) Logical disputing - involves the therapist challenging irrational thoughts to show that they do not logically follow from the information available / facts (e.g. does it make sense that your friend doesn’t text you back immediately that he hates you?)
2) Empirical disputing - involves the therapist challenging irrational thoughts to show that they may not be consistent with reality (e.g. where is the proof that the thought that you have no friends is accurate) - the therapist would also present evidence to act as a counterargument e.g. messages from friends that are asking the person to come to dinner with them
3) Pragmatic disputing - is it a practical thought?

The intended effect is to change the irrational thoughts and so break the link between negative life events and depression, and changing the thoughts therefore leads to healthier emotions, and the symptoms of depression are alleviated.

Question 17

REBT - Homework and Behavioural activation

Answer 17

Homework -

• Clients are often asked to complete HW assignments between therapy sessions, and this might include asking a person out on a date when they have been to afraid to do so for fear of rejection, looking for a new job, asking friends to tell them what they really think of the person etc
• Such homework is vital in testing irrational thoughts against reality and putting new rational beliefs into practice

Behavioural activation -

• CBT often involves a specific focus on encouraging depressed clients to become more active and engage in pleasurable activities
• This is based on the common-sense idea that being active leads to rewards that act as an antidote to depression
• Such activity then provides more evidence of the irrational nature of the client’s thoughts

Question 18

Genetic explanation for depression

Answer 18

• Centers on the idea that vulnerability to depression is inherited, and this is generally researcher with twin or adoption studies, as well as gene-mapping studies that compare genetic material between those with high and low incidences of the disorder
• Wender et al (1986) found that adopted children who develop depression were more likely to have a depressive biological parent, even though they are raised in different, suggesting that biological factors are more important than cognitive ones environment
• Plomin et al (2013) used a gene mapping technique and found that genetics accounted for about 66% of the heritability of cognitive abilities, suggesting that negative schemas may have a large genetic component to them illustrating how genetic and cognitive explanations can be combined to give a better explanation of the origin of the disorder

Question 19

Behavioural explanation for depression

Answer 19

• Sees depression as a learned condition - Lewinsohn (1974) suggested that negative life events may incur a decline in positive reinforcements and even lead to learned helplessness, where individuals learn through experience they cannot seem to have positive life outcomes
• Depression can even from social learning, by the observation and imitation of depressed others
• Maier and Seligman (1976) found that participants placed in a situation where escape from noise or shocks were impossible didn’t try to escape from future similar situations where escape was possible, lending support to the idea of learned helplessness
• Coleman (1986) found that individuals receiving low rates of positive reinforcement for social behaviors became increasingly passive and non-responsive. leading to depressive moods, which provided support for Lewinsohn’s learning theory

Question 20

Research into the effectiveness of CBT

Answer 20

1) Lincoln et al used a questionnaire to identify stroke victims who had developed clinical depression - 19 patients were then given CBT sessions for four months had reduced symptoms , suggesting CBT is a suitable treatment for specific groups of depressives
2) Whitfield and Williams (2003) found CBT had the strongest research base for effectiveness, but recognized an issue in the NHS being able to deliver weekly face-to-face sessions for patients and suggested that this could be addressed by introducing self-help versions of the treatment such as the SPIRIT course which teaches core cognitive behavioral skills using self-help material
3) David et al (2008) found using 170 patients suffering from major depressive disorder, that patients treated with 14 weeks of REBT had better treatment outcomes than those treated with the drug fluoxetine 6 months after treatment, and this suggests that REBT is a better long-term treatment than drug therapy

Question 21

Evaluating CBT - Strengths

Answer 21

1) Research support - Ellis 1957 claimed a 90% success rate for REBT, taking an average of 27 sessions to complete the treatment, and REBT have done well in outcome studies of depression
- A review of 75 studies by Cuijpers et al in 2013 found that CBT was superior to no treatment, but Ellis recognised that the therapy was not always effective and suggested that this could be because some clients did not put their revised beliefs into action (Ellis, 2001)
- Therapist competence also appears to explain a significant amount of the variation in CBT outcomes and this suggests that REBT is effective but other factors relating to both client and therapist may limit its effectiveness - some weakness but mostly effective

2) Alternative treatments - other treatments are available, such as the use of antidepressants like SSRIs; drug therapies have the strength of requiring less effort from the client (less commitment) and they can also be used in conjunction with a psychotherapy like CBT
- This may be useful because a distressed client may be unable to focus on the demands of CBT and the drug treatment could enable them to cope better
- The Cuijpers review found that CBT was especially effective if it was used in conjunction with drug therapy
- This suggests that using both CBT and drugs might be the best option - CBT is a good way to avoid medication and avoid damaging your brain chemistry
- CBT is just as effective as drugs, and it is better to treat more naturally and is effective as a permanent treatment

Question 22

Evaluation of CBT - Strengths cont.

Answer 22

3) Support for behavioural activation - the belief that changing behaviour can go some way to alleviating depression is supported by a study on the beneficial effects of exercise - Babyak et al (2000) studied 156 adult volunteers diagnosed with major depressive disorder
- They were randomly assigned to a four month course of aerobic exercise, drug treatment or a combination of the two
- Clients in all three groups showed significant improvement at the end of the 4 months, and 6 months after the end of the study, those in the exercise group had significantly lower relapse rates than those in the medication group
- This shows that a change in behaviour can be beneficial to treating depression - external validity

Question 23

Evaluation of CBT - Weaknesses

Answer 23

1) Ignores aspects of peoples lives, ignores brain chemistry, expensive, ignores circumstance - poor internal validity

2) Not appropriate for everyone - severely depressed people who cannot do the homework etc;
- Individual differences - CBT is more suitable for some individuals than others, such as being less suitable for people who have high levels of irrational beliefs that are both rigid and resistant to change (Elkin et al 1985)
- CBT also appears to be less suitable in situations where high levels of stress in the individual reflect realistic stressors in the person’s life that therapy cannot resolve (Simons et al 1995)
- Ellis also explained a possible lack of success in terms of suitability, as some people simply do not want the direct sort of advice that CBT practitioners tend to dispense, and they prefer to share their worries with a therapist without getting involved in the cognitive effort of recovery
- A limitation of CBT s therefore that individual differences limit its appropriateness for all people and its effectiveness as a result

Question 24

Evaluation of CBT - Weaknesses cont.

Answer 24

3) The ‘Dodo Bird Effect’ - all methods of treatment for mental disorders may be equally effective
- Rosenzweig (1936) named this effect as research tends to find fairly small differences in success rates - Luborsky et al (1975, 2002) reviewed over 100 studies that compared different therapies and found that there were only small differences
- R argued that the lack of difference was because there were so many common factors in the various different psychotherapies, such as being able to talk to a sympathetic person (which may enhance self-esteem) and having an opportunity to express ones thoughts (Sloane et al 1975)
- These commonalities, therefore, might explain the lack of difference in the effectiveness of different therapies