Sunday, 25 January 2015

When Cognitive Therapy Began

Perhaps relatively few people undergoing cognitive therapy will have given much thought to its roots or development. It’s perfectly understandable as every medicine, clinical procedure and therapy has its own story, and we can’t know them all. The thing I find interesting about cognitive therapy is the way, in a comparatively short length of time, it has developed and been accepted as a mainstream therapy for depression. I still remember being taught the basics it as if they were hot off the press, although in many ways they were. So I thought in this post I’d take a little time to look back over how the whole thing started and share some of the basic ideas behind the model.

The psychiatrist Aaron Beck is widely regarded as the father of cognitive therapy. During his many consultations Beck was struck by the number of times his patients used self-criticism and assumed personal blame for their feelings. They would frequently view others as having purpose, meaning and happiness in their lives, and this often served to exaggerate their own perceived misfortunes, helplessness and futility. What Beck did next was to suggest a model of depression that has stimulated research for the past 40 years.

Beck suggested that the core of depression consisted of three key elements. The first of these was the so-called ‘cognitive triad’ made up of negative issues around the self, the world and the future. Beck suggested that people with depression have distorted thinking and tend to focus on negative aspects rather than the whole picture. This form of distortion is often exaggerated and magnified, a feature he described as ‘faulty information processing’ and which comprised the second of the key elements.

The ‘negative self-schema’ is the third element suggested by Beck. The word schema simply means shape, so a self-schema refers to the cluster of ideas and beliefs we have of ourselves. We may, for example, view ourselves as quiet and thoughtful, or stupid and thick, or loud and outgoing. Our schema inevitably incorporates our health status where we might view ourselves as robust, or sickly, and so on. According to Beck, people with depression have a negative self-schema which was probably acquired during childhood, most likely from critical, demanding or rejecting parents.

Beck’s model of depression effectively provided a platform for a new form of therapy in which the therapist works with a patient in order to identify and change patterns of thinking, behavior and emotions that may not only lead to depression but help to maintain it. Since the mid 1960s and 70s when the model first became prominent, it has been revised and adapted. The Beck Depression Inventory is still one of the most commonly used ways for measuring the severity of depression. Meanwhile, the Beck Institute continues to thrive under the Presidency of Aaron Beck’s daughter, Dr. Judith Beck.

Saturday, 24 January 2015

Can Stress Cause Depression?

What exactly is a stressful experience? We can look at it in different ways. First, we have negative life events such as divorce or bereavement. There are the everyday hassles to which most of us are exposed. Then we might consider more chronic difficulties such as living with a disease or disability, or perhaps being a caregiver for someone with a long-term disease. Last, but not necessarily least, are the childhood experiences that help to shape our view of the world and our place in it.

In my first few years working in mental health, depression tended to be described in one of two ways. Reactive depression was thought to result from stressful life events and the prognosis was considered more favorable than those with endogenous (from within) depression. In fact there is very little evidence to support such differences. Even the so-called endogenous depressions tend to be triggered by stressors and the clinical features and treatments of the two are similar.

We know that loss, is one of the key ingredients for depression. Interpersonal loss, in the form of bereavement, separations, endings, or even the threat of such things, have a negative effect on the self-worth of people, some of whom may be especially vulnerable. There is evidence to suggest such events frequently precede depression and may indeed be one of the most common issues. But loss isn’t simply to do with relationships. Loss can be extended beyond the interpersonal to include, for example, loss of employment, status and loss of self-esteem.

Having said this, the fact remains that even in the face of extreme stress, most people do not go on to develop major depression. This leads us to the notion that some people must have a particular vulnerability and this is where things begin to get tricky. Most of the current thinking around this vulnerability talks of an interplay between biology, social circumstances and psychology. The complexity of such models makes analysis extremely difficult.

There is evidence that stress can lead to depression but we can’t assume this is a one-way relationship. The personal characteristics of individuals also means that depression can result in stressful events. Whatever the relationship, it appears that the stress-depression link is far from static. The nature of the relationship is complex and may even change for the individual over time.