Cognitive Behavioral Treatment for Chronic Depression

Individuals with chronic depression are often disconnected from the environment, meaning the consequences of their behavior do not impact  their future behavior. Cognitive Behavioral Assessment System of Psychotherapy (CBASP) is the only treatment model developed specifically for the disconnection involved with chronic depression (Shatzberg et al., 2005). It is the subject of the largest study on psychotherapy in history, and has shown to be significantly more effective than other treatments for chronic depression. 

According to the CBASP model, maltreatment and trauma experienced early in life can derail normal psychological development, and results in early-onset chronic depression. Such maltreatment can take many forms, from physical abuse to perceived invalidation. Alternatively, an out-of-control mood state in the late-onset patients can also undermine psychological functioning in people with no history of neglect or abuse. Significant life events such as the onset of chronic illness, loss, and divorce can trigger such a mood state and result in lasting feelings of sadness and dispair. Research indicates CBASP therapy is one of the few treatments than can effectively treat both early- and late-onset chronic depression.

In CBASP, patients examine the specific consequences of their interpersonal behavior. During this retraining, patients learn to become more perceptually connected to their environment, observing where their behavior is working against them. This goal is accomplished through a technique known as situational analysis. In situational analysis, the patient’s attention is directed to the effect of her behavior on others as well as the effect of her interpersonal behavior on the therapist. During CBASP, the interpersonal trauma the patient brings to treatment is healed by piecing apart those elements of the patient’s past she is projecting onto the present. An Exercise called the Interpersonal Discrimination Exercise helps to highlight this, by demonstrating to the patient how the therapist differs from past maltreating significant others.

This treatment has been shown to be highly effective in people whose depression symptoms do not respond to traditional talk therapy or to antidepressant medication. Click here for more information about cognitive behavioral treatment of depression


Shatzberg, A.F. et al. (2005). Medication or therapy is effective when the other is not. Archives of General Psychiatry, 62, 513-520.

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Behavioral Activation to Treat Depression

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It is estimated that in 2016, over 16 million adults in the U.S. had a major depressive episode. This represents almost 7% of all adults in the United States. Even more shocking, this number only accounts for a small subset of individuals with depression, as not everyone with clinical depression meets the diagnostic criteria for a major depressive episode. Sadly, most people suffering with depression do not seek treatment despite the development of very effective treatment methods in the last few years. Recent research has demonstrated that cognitive behavioral therapy is the gold standard in treating depression.

Cognitive-behavioral models of depression have long held that depression is the result of an interaction between thoughts, feelings, and behavior (e.g., Beck et al., 1979; Rehm, 1977). Simply put, situations trigger some response of one of these elements, for example, thoughts. The thoughts then cause a chain reaction in which feelings are influenced, which in turn trigger behaviors, often resulting in a kind of emotional snowball with a momentum of its own. An example of this is someone not being invited to go out after work with the rest of one’s coworkers. This may trigger the thought “No one likes me.” As a result of this thought, sadness is elicited, causing the person to go straight home and lie in bed. Having only one’s negative thoughts to occupy one’s mind, this cycle becomes stronger and stronger.

The cognitive behavioral approach to therapy is to target the thoughts, the behavior, or both to break the momentum of this system and inspire new emotions, thoughts, and behaviors to arise. Significant evidence suggests that merely increasing rewarding behaviors is a very effective way to effectively treat depression. Behavioral Activation (Martell et al., 2010) is a CBT treatment that has shown significant success in research studies. In fact, Behavioral Activation has been shown to be just as effective as antidepressant medication at reducing depressive symptoms, and even more effective than medication at keeping the symptoms from recurring after treatment (Dobson et al., 2008).

The premise of behavioral activation treatment is that once we get in a depressive cycle, we slowly withdraw from activities that are rewarding. People who are depressed often spend too much time in bed, watching TV, avoiding people and beneficial activities. Behavioral activation is about gradually re-introducing rewarding activities back into people’s routines. These activities can either be pleasurable, such as going for a walk or scheduling dinner with a friend, or mastery-oriented, such as painting the bedroom or volunteering at a charity. After a period of consistently engaging in reinforcing activities, mood gradually improves, resulting in less self-defeating thoughts, and the upward mood cycle builds momentum.

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The primary way of going about behavioral activation is through activity monitoring and activity scheduling. Keeping a detailed record of behavior during the week as well as tracking feelings of pleasure and mastery associated with each behavior, serve as a guide to what might be missing from your routine. After tracking this for a few days to a week, the following weeks are spent gradually increasing rewarding behavior into your day by scheduling the new rewarding behaviors. In this way, people can come out of their depressive cycles by replacing them with contentment cycles. Sounds simple, but in practice it can be quite difficult to engage in any activity when you’re feeling unmotivated.  Consequently, behavioral activation is usually most effective with the help of a trained cognitive-behavioral therapist, who knows techniques to aid behavior modification and knows how to avoid potential pitfalls that can derail progress early on. Studies have shown behavioral activation for depression with a CBT therapist can improve symptoms after just the first session, with most people showing significant symptom reduction/remission after as few as 12 sessions.

If you or someone you know is struggling with depression, behavioral activation may be the right treatment for you. For more information on cognitive behavioral therapy and cognitive behavioral treatment of depression, visit Cognitive Behavioral Therapy Los Angeles.

 

Beck, A.T. et al. (1979). Cognitive Therapy of Depression. New York: Guilford.

Dobson, K.S. et al. (2008). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology, 76, 3, 468-477.

Rehm, L.P. (1977). A self-control model of depression. Behavior Therapy, 8, 787-804.

Martell, C.R., Dimidjian, S, & Herman-Dunn, R. (2010). Behavioral Activation for Depression. New York: Guilford.