Cognitivebehavioural Models

There are a number of theoretical and clinical models of depression in both the behavioural and the cognitive literatures. Early behavioural models (e.g., Lewinsohn, 1974) tended to focus on the symptoms of anhedonia (see above) with the general assumption that reduced rates of positive reinforcement, or lower rates of self-reinforcement that would follow from a withdrawal from everyday activities, would lead to a state of depression. Seligman's (1975) learned helplessness model initially argued that it was the lack of control over reinforcement that was more important than whether or not the patient received reinforcement. However, as we have pointed out elsewhere (Power & Wykes, 1996), the learned helplessness model would predict that people should become depressed if an anonymous well-wisher dropped £100 through their letter box every week, an idea that we definitely find counter-intuitive. Although it has become clear, as we will discuss in detail below, that the straightforward behavioural models are too simplistic in their accounts of depression, because they focus primarily on anhedonia, in the treatment of depression the early assessment and, if needed, intervention in activity levels has become a standard part of cognitive-behavioural approaches.

We will concentrate in this chapter on the main CBT approach to depression, that of Beck (1976). However, it should first be pointed out that Beck's theory was in fact presaged by the work of the ego analyst Bibring (1953), who revised Freud's original psychoanalytic formulation (presented in his classic work, Mourning and Melancholia [1917]). Bibring proposed that it was the failure of certain aspirations, such as to be loved or to be admired, that was the primary cause of depression in vulnerable individuals. Although it is unclear to what extent Beck was influenced by Bibring's work (Weishaar, 1993), this idea lies at the core of Beck's cognitive therapy.

The general cognitive therapy model of depression is outlined in Figure 8.1. The figure shows that dysfunctional schemas are typically formed in childhood as a consequence of socialisation processes developed in interaction with parents and other significant individuals within the child's social network. These early socialisation processes lead the child to believe that his or her worth is especially dependent on the views of others, or that self-worth can be achieved only through the successful pursuit of certain goals and through gaining the admiration of others. Beck (1983) characterised dependent individuals as "sociotropic", and achievement-oriented individuals who often avoid dependency on others as "autonomous".

EARLY EXPERIENCE (e.g., criticism and rejection by parents)

FORMULATION OF DYSFUNCTIONAL ASSUMPTIONS (e.g., unless I am loved I am worthless)

CRITICAL INCIDENTS (e.g., loss events)

ACTIVATION OF ASSUMPTION NEGATIVE AUTOMATIC THOUGHTS DEPRESSION

Figure 8.1 A summary of Beck's model of depression

Within the model, both types of individual are considered to have dysfunctional schemas which are normally latent, but which become activated when a negative event occurs that matches that particular schema. For example, the adolescent who has an excessive need to be loved by others may find that the first rejection in a love relationship leads to a state of depression in which the self is believed to be unlovable and worthless. Of course, not everyone who has the dysfunctional schemas need become depressed; the successful pursuit of a role or goal may prevent some individuals from becoming depressed despite their vulnerability. This model may also explain why some individuals might become depressed for the first time only later in life (e.g., Champion & Power, 1995).

Figure 8.1 also shows that activation of dysfunctional schemas leads to a range of cognitive phenomena that form the focus of the main part of therapy. One of the innovations of Beck's approach was the focus on so-called negative automatic thoughts (NATs), the experience of which typically leads the individual to believe that he or she is a failure. For example, a thought such as "I'm worthless" or "No one will ever love me" can lead to a sudden downturn in mood; one of the aims of therapy therefore is to help the individual identify what these NATs are and, subsequently, to learn how to challenge them rather than simply believe them to be absolute truths.

A second feature of cognitive processes that are consequent on the activation of the dysfunctional schemas is that they lead to so-called logical errors of thinking. These logical errors have been variously grouped into the following sorts of categories (Beck et al., 1979):

(1) All-or-nothing thinking: "If I can't do it perfectly, there's no point in doing it at all."

(2) Overgeneralisation: "I always get things wrong."

(3) Discounting the positive (selective abstraction): "I've finished my work today, but I should have done more."

(4) Jumping to conclusions (mind-reading): "Everyone is fed up with me because I'm depressed again."

(5) Catastrophising (magnification and minimisation): "It's all going to go wrong, and I can't change it."

(6) Emotional reasoning: "I feel bad therefore I must have done something wrong."

(7) Shoulds: "I should pull my socks up and get on with it."

(8) Personalisation: "It always rains when I arrange to go out."

In the early writings on cognitive therapy, these logical errors were presented in a way that implied that depressed individuals are irrational and illogical in their thinking, with the implication that normal individuals are rational and logical. However, more recent analyses have accepted the demonstrations from studies of reasoning in normal individuals that such individuals may also demonstrate characteristic biases (e.g., Garnham & Oakhill, 1996), and even that under certain conditions depressed individuals may be more accurate rather than less accurate than normal controls (e.g., Alloy & Abramson, 1979). Cognitive therapists now assume, therefore, that depression causes self-related information processing to be biased in a negative way (e.g., Haaga et al., 1991; Weishaar, 1993). A negative bias does not, however, invariably imply a distortion of information processing (see Power & Dalgleish, 1997). In fact, normal non-depressed individuals typically are mildly positively biased for self-related information processing and are also prone to the same types of logical errors as are depressed individuals, but in the opposite direction, as the following examples illustrate (Power & Wykes, 1996):

(1) All-or-nothing thinking: "This place would fall apart without me."

(2) Overgeneralisation: "You know I'm always right."

(3) Discounting the negative (selective abstraction): "I was just doing my duty and following orders."

(4) Jumping to conclusions (mind-reading): "I feel happy and everyone thinks I'm wonderful."

(5) Magnification and minimisation: "If I were running the country, I'd soon sort this mess out."

(6) Emotional reasoning: "I feel so good I know I'm going to win the National Lottery today."

(7) Shoulds: "Other people should pay me more respect and recognise my talents."

(8) Personalisation: "The sun always shines when I arrange to go out."

The moral of this story is that both normal and depressed individuals can be biased in how they process information, though the biases are typically positive for normal individuals and negative for depressed individuals. Therefore, the task of the therapist is made even more difficult than the original cognitive therapy approach implied, in that some of the depressed client's negative statements may be incisively accurate. The therapist should not be misled into thinking, however, that the accuracy of some negative statements means that all negative statements are true, for therein lies the therapist's skill in distinguishing one from the other (Power, 2002).

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