I hope everyone had a wonderful holiday! After a brief hiatus from blogging, I'm back.
Since I usually focus on pharmacological treatments for depression, I've decided to focus a little more on talk and behavior-based therapies for awhile. I'll begin with cognitive behavioral therapy (CBT)--one of the most popular evidence-based talk therapies used to treat depression, and one that I've utilized during both periods of illness and health.
CBT is a standard treatment for mood disorders. Research shows that it is fast, effective, and relatively inexpensive; in as little as 6-10 sessions it can reroute wayward thinking processes, and rewire the brain. The premise of CBT is simple: thoughts give rise to feelings, and thoughts that are negatively distorted cause depression. Thus, by challenging distorted thoughts patients can gain a more realistic (which is hopefully a more positive) outlook.
Cognitive distortions that CBT addresses include catastrophizing, overemphasizing negative cues, discounting positive cues, taking things personally, and all-or-nothing thinking, etc. See this for a list of other common distortions.
This article in American Family Physician explains how CBT works:
First, the patient accepts that some of his or her perceptions and interpretations of reality may be false (because of past experience or hereditary or biological reasons) and that these interpretations lead to negative thoughts. Next, the patient learns to recognize the negative (surface or “automatic”) thoughts and discovers alternative thoughts that reflect reality more closely. The patient then decides internally whether the evidence supports the negative thought or the alternative thought. Ideally, the patient will recognize distorted thinking and “reframe” the situation. As cognitive therapy progresses, it focuses more on reframing deeply held or “core” beliefs about self and the world . . . .
In cognitive behavior therapy (CBT) for depression, behavioral principles are used to overcome a patient’s inertia at the beginning of therapy and to reinforce positive activities. An important part of CBT for depression is scheduling pleasurable activities, especially with others, that usually give positive reinforcement.
CBT taught me to stop beating myself up. It helped me realize that the things I said to myself were more harsh, hateful, and explicit than anything I would ever say to another person. And if I wouldn't talk to another person that way, I shouldn't accept such vicious self-talk. It also helped me do away with negative distortions that had crystallized into automatic assumptions in my mind. For example, I learned not to catastrophize and globalize negative events; that is, I learned not to respond to a negative event with thoughts like "I'll screw everything up" "I'll never succeed" or "People will always hate me". Instead, I began to recognize that making one error is just that--one error--not an indictment of my competency or worth.
CBT has been invaluable in reframing my thoughts when I am well enough to employ its techniques. However, several times I have descended beyond the reach of CBT. At those times only medication put any dent in my depression. In those cases, when severe depression swept me away, CBT was like a rescue rope that didn't quite reach. I needed something more—I needed a rescue helicopter. Eventually the medication lifted me up to a point where I could engage in therapy, and the two treatments worked in harmony.
While I think CBT is great for mild, moderate, and/or early stage depression, I'm not convinced that CBT works for severe depression. In my experience the chain of causation in severe depression is not thoughts-->feelings, but rather feelings-->thoughts. It's just my theory, but I think that when the disorder becomes severe feelings are so intense that the mind struggles to make sense of them--somtimes with delusional explanations. In my case, feelings of extreme guilt seemed to precede and give rise to the thought that I must have harmed someone. I suspect there is a feedback loop between thoughts and emotions, and while the current may run from thoughts-->feelings in mild types of depression, it may reverse as the illness progresses.
Another possible limitation of CBT is its inability to address thoughts which aren't distorted--accurate perceptions of things that really are bad. There are errors we all make that are undeniably bad, and shouldn’t be excused or minimized because doing so risks denying the truth of such transgressions. CBT produces a healthy mindset for addressing these issues, but it doesn't seem to do the heavy lifting that helps one process and accept these types of experiences. I also question the efficacy of CBT in dealing with grief.
Overall, however, I think CBT is a critical tool in recovering from--and preventing--depression. And because distorted thinking patterns have a way of creeping back into the mind, CBT is something that can and should be continued even once depression recedes. The techniques that CBT teaches need to be practiced and strengthened like any exercise. Moodgym is a website that takes user through a CBT “training program”.
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