Major Depressive Disorder – Behavioral and Cognitive Perspectives and a Review of Cbt Essay Example

will be reviewed. This review will analyse the efficacy of CBT strategies in comparison to alternate MDD therapies, culminating in conclusions regarding the current status of CBT treatments for MDD.

Strict behaviorism suggests that as the inner workings of the human mind (i. e. cognitions) are not observable, scientific psychology should be rooted solely in the study of behaviour (Martin, Carlson, & Buskist, 2007).In the simplest sense, behaviourist learning theories suggest that behaviours which produce favourable outcomes will be repeated (and may become habits), while behaviours that produce unfavourable outcomes are less likely to be repeated (Ouellette & Wood, 1998). This core principle provides the bedrock for the behavioral perspective of all learning. Skinner (1953) elaborated upon this basic principle, proposing the theory of operant conditioning as the basis for the relationship between human behaviour and the environment.

Operant conditioning suggests a three-term contingency, where discriminative stimuli precipitate behaviour (a response), which in turn leads to consequences. By manipulating relations among the contingencies in controlled animal studies, Skinner found behaviours were more likely to occur if they were positively or negatively reinforced, or less likely to occur if they elicited aversive (punishment) or no (extinction) consequences (for a review, see Martin, Carlson, & Buskist, 2007). While further elaboration of the operant framework (e. g. ocial learning theory, Bandura, 1969) expanded the understanding of human learning, structured behavioural analysis and its application to human problem solving can be attributed to the pioneering work of Skinner (Mazur, 1994). Specific behavioural conceptions of ‘depression’ have been formulated within the operant framework.

Collectively these conceptions focus on absent behaviours, or ‘inactivity’, as the chief protagonist in the emergence and maintenance of depression

(Ferster, 1973; Jacobson, Martell, & Dimidjian, 2001; Lewinsohn & Libet, 1972). Lewinsohn and Libert (1972) suggest decreases in pleasant events, or increases in aversive events, are associated with the onset of depression. Ferster (1973) extends upon this conception in his functional analysis, suggesting that depression is maintained by avoidance, a form of negative reinforcement. This negative reinforcement is the result of the removal of anxiety (an aversive stimulus) that might otherwise be experienced while participating in social activity (Ferster, 1973).

In summary, Ferster asserts that anxiety reducing avoidant behaviour provides negative reinforcement for inactivity. This inactivity also reduces participation in activities usually regarded as pleasant, thus decreasing the possibility of positive reinforcement. The resultant cycle of decreasing activity maintains and prolongs depression. In line with this thinking, behavioural treatment strategies for depression aim to increase activity via positive reinforcement. The behavioural tools of functional analysis, social skills training, and activity scheduling are central to this approach (Jacobson, Martell, & Dimidjian, 2001). Clark, Hollifield, Leahy, and Beck (2008) suggest cognitive theories of psychological disorders emerged as a result of dissatisfaction with such purely behavioural theories.

The core principle of cognitive theory suggests human information processing plays a role in human adaption and well-being, thus humans respond to their internal representations of the environment, rather than the environment itself (Clark, Hollifield, Leahy, & Beck, 2008). It is suggested that these cognitive representations (i. . thoughts, attitudes, beliefs) can be studied and modified, and that such modifications can impact human emotion and promote adaptive behaviours (Clark et al.

, 2008). The cognitive model of depression was developed by Beck (1967; 1979), and while modifications and alternate models can be found in

the literature (e. g. cognitive-behavioural analysis system of psychotherapy, McCullough, 2000), the pre-eminence and influence of Beck’s model make it the focus of this review. Beck’s model incorporates three cognitive constructs; the cognitive triad, schemata, and cognitive distortions.

The cognitive triad refers to individuals views about themselves, the future, and the world. Beck suggests that negative thinking patterns surrounding this triad lead to persistent expectations of failure and rejection, and feelings of worthlessness in the depressed individual. Schemata are viewed as internal representations that are easily accessed and allow new information to be integrated and organized in a quick and meaningful manner. Beck posits that negative self-schemata help maintain depression in the depressed individual by influencing the interpretation of daily experience in a negative fashion.

Cognitive distortions are defined as misinterpretations of reality that are seen as confirming a depressed person’s negative expectations. Beck suggests such errors in logic are not general cognitive deficits, but rather specific misrepresentations related to the self and self-image. These errors include selective abstraction, overgeneralisation, arbitrary influence, personalisation, and dichotomous (all or nothing) thinking. While dysfunctional cognitive processes are seen as neither necessary nor sufficient to induce and maintain depression, Beck (1987, as cited in Clark et al., 2008) suggests these underlying negative constructs lay dormant in the individual susceptible to depression until activated by stressful life events.

This accounts for the cognitive conception of depression being considered a stress-diathesis model (Clark et al., 2008), and is also in line with behavioural explanations for the onset of depression. The key difference between the conceptions, as one may expect, is that cognitive theory outlines depression as the activation of maladaptive cognitive constructs, rather than

maladaptive behaviours, in response to aversive environmental stimuli. In summary, Beck (1967; 1979) suggests stressful life events matching individual areas of cognitive susceptibility activate negative self-constructs, which in turn lead to further cognitive dysfunction including mood deflating negative automatic thoughts. Collectively, Beck suggests these negative self-constructs and resulting cognitive dysfunctions maintain and support depressive symptoms. While the therapy emanating from Beck’s (1967, 1979) model of depression was coined cognitive therapy (CT), it is widely regarded as and remains the pre-eminent, cognitive behavioural therapy (CBT).

At a general level, CBT is an umbrella term describing all psychological therapies that incorporate a cognitive model for a disorder while utilising behavioural tools and techniques as part of the therapeutic process. In the case of depression (and thus MDD), CT is historically synonymous with CBT and the terms are interchanged freely in the literature. In line with this approach, the term CBT will be applied to CT for the remainder of this review. CBT for depression is conceived as a short term (2-4 months) treatment strategy that is personalised for each individual (Beck, 1979). General CBT themes include the use of core therapist skills such as empathy and genuineness, and the constant encouragement of feedback and questioning to ensure client understanding of covered material (Friedman & Thase, 2007). As suggested above, CBT incorporates the core methods of behaviour therapy in the treatment of depression.

Friedman and Thase (2007) suggest activity scheduling, individualised homework, guided practice, and graded task assignments are key elements of CBT; however rather than simply ‘promoting activity’, each is used strategically to bring about client recognition of problem areas and achieve change in negative thoughts and schemas. In

encouraging the use of these strategies, the CBT therapist is encouraged to assume the role of coach or teacher in the process of cognitive change (Beck, 1979). A generic CBT treatment plan for depression may be summarised in the following manner. Initial session/s will foster the client/therapist relationship and include information gathering and diagnosis.

Included in initial sessions is a review of the cognitive model for MDD, and an explanation of how that model applies to the personal situation of the client. Early in the treatment process (particularly for more severe cases of MDD), there is a greater emphasis placed on behavioural techniques. Functional analysis of behaviour and the daily monitoring of moods and activities will be undertaken at this early stage. A key requirement for the therapist is to ensure these tasks are clearly explained as a means of understanding the functional relationship between activities, moods, and automatic thoughts.

Through generating this understanding the therapist aims to increase client participation in rewarding activities. Once initial information gathering, model explanation, and basic functional analysis has been undertaken, CBT sessions take on a highly structured, repetitive format. In each session homework is reviewed, set backs discussed, session goals devised, one or two problem areas addressed, and feedback obtained. These sessions are organised in a graded fashion where problems are addressed at a pace appropriate for the client’s progress and ability to use abstract thought. The sessions move toward testing the accuracy of negative automatic thoughts, and eventually negative self-schemas.

Both behavioural experiments and ‘Socratic-like’ methods may be used to challenge these cognitive dysfunctions. Therapeutic strategies such as the Daily Record of Dysfunctional Thoughts may be used to aid this

process. To conclude each session, long term goals and progress may be reviewed, and homework is set to reinforce covered material. The final session/s of CBT for MDD will typically involve a review of skills learned geared toward relapse prevention. Such sessions include a review of the cognitive model with a focus on defective schemas and their possible means of activation. By reinforcing the functional awareness the client has gained, and generalising the problem solving skills the client has developed, self help plans are designed with the aim of maintaining cognitive change and maximising the long term benefits of CBT.

Butler, Chapman, Forman, & Beck (2006) report CBT to be one the most widely researched forms of psychotherapy. While early meta-analyses (e. . Dobson, 1989) reported CBT to have effect sizes superior to pharmacology and other forms of psychotherapy, subsequent criticisms regarding reviewer bias (Gaffan, Tsaouis, Kemp-Wheeler, 1995) bring the standing of such studies into question. The meta-analysis of Gloaguen, Contraux, Cucherat, and Blackburn (1998) is regarded as methodologically rigorous (Butler et al., 2006), and thus provides a suitable starting point for review. Gloaguen et al. (1998) found that over 48 suitably controlled depression studies, CBT produced clinically significant change superior to waiting list and controls (29% patient benefit, ES = . 2), antidepressants (15% patient benefit, ES = .38), and other miscellaneous therapies (10% patient benefit, ES = . 24). No significant difference was found between behavioural therapies and CBT. These results are broadly in line with the later meta-analysis of Hollon, Thase, and Markowitz (2002), however no significant advantage was found for depression-focused CBT over pharmacological treatments.

Two notable exceptions in the general trend of

support for relative CBT efficacy can be found in the literature. In a large placebo-controlled trial of CBT versus anti-depressants, Elkin et al. 1989) found CBT to be less effective than pharmacotherapy (particularly for severely depressed patients) and reported effect sizes close to that of placebo. Similarly conducted later trials however found parity between CBT and medication treatments (DeRubeis et al. , 2005a; Jarret et al., 1999). The quality of the CBT provided in the Elkin et al. study has subsequently been questioned (Jacobson & Hollon, 1996).

In a second departure from the norm, Parker, Roy and Eyers (2003) combined earlier meta-analysis with primary studies and suggested the success of CBT had been overstated. The quality of this study however has been questioned due to the omission of high quality studies favourable to CBT (Butler et al., 2005). Other notable findings suggest comparable efficacy for CBT in group settings to that of individual CBT (Oei & Dingle, 2008), and an advantage for CBT over discontinued pharmacotherapy in terms of relapse prevention (DeRubeis et al., 2005b).

The proliferation of research on CBT for MDD has also led to the emergence of correlates, or possible predictors of response (for a detailed review, see Friedman & Thase, 2007). Higher rates of comorbid disorders, single or unmarried status, high pretreatment levels of dysfunctional attitudes, chronic features, and increased initial symptom severity have been associated with poorer outcomes for MDD patients. Higher pretreatment levels of optimism, motivation, and self-efficacy, along with the ability of the therapist to adequately structure the individualised CBT program, have each been associated with more positive outcomes for MDD sufferers. In summary, it is suggested that while the

behavioural and cognitive perspectives agree that environmental stressors or aversive stimuli precipitate MDD, each differs in its explanation for the development and maintenance of the disorder. These differences can be traced to the core principles of each paradigm. CBT for MDD (or CT, Beck, 1979) is a highly structured therapy based on a detailed cognitive model; both cognitive and behavioural techniques are utilised in the aim of producing cognitive change.

Research suggests that while individual results may vary, CBT displays general efficacy for the treatment of MDD.For the average patient, CBT performs on par with therapies termed ‘behavioural’, however the ‘pure behavioural’ status of such therapies can be questioned. Weight of evidence suggests anti-depressants enjoy short term parity with CBT; however CBT may outperform discontinued pharmacology in terms of relapse prevention (DeRubeis et al., 2005b). These general conclusions are supported by current treatment summaries for psychiatric disorders (e. g. Friedman & Thase, 2007).

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