Clinical interview

Assessment for cognitive-behaviour therapy also includes exploration of the following factors. Symptoms and associated cognitions

Negative automatic thoughts both trigger and enhance symptoms of depression (see Table 1 for examples). Identifying meanings attached to symptoms prepares the ground for more helpful perspectives (e.g. 'These are symptoms of depression, not a reflection of my worth as a person').

Table 1 Negative automatic thoughts and symptoms of depression

Impact on functioning

It is important to establish how depression affects relationships, work performance, and leisure time. It may be necessary to take practical steps to improve the patient's situation (e.g. gradual reintroduction to work). Cognitive-behavioural methods are used to address reservations and doubts (e.g. 'I haven't the energy', 'I'll never get my job back').

Coping strategies

The more depressed the patient, the more likely that he or she will have adopted coping strategies which provide relief in the short term, but are in the longer term self-defeating (e.g. use of alcohol or drugs, social withdrawal, lying in bed). The therapist and patient can discuss the pros and cons of these, and how cognitive-behavioural strategies might be more beneficial. The aim is for patients to reach the point of trying more adaptive coping strategies for themselves. Again, reservations can be directly addressed.

Onset of current episode

Information about the onset of episodes and other periods of distress may provide valuable clues about beliefs and assumptions. For example, a young woman became depressed when her husband took a job abroad, which meant he was away for several weeks at a time. She believed that he would not have done so if he truly loved her. In fact, he had taken the job because it paid exceptionally well and the savings they could make would allow them to start the family they had been planning. The therapist noted the patient's interpretation of her husband's behaviour, and later in therapy used this clue as a starting point to identify long-standing doubts about her attractiveness, and a linked dysfunctional assumption: 'If someone is not there for me all the time, it means they don't care about me'.

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