Depression is a common experience among most people who must put up with the demands placed on them by work, family and the society. However, unlike mild depression which many people overcome without seeking medical intervention, Fennell1 defines severe depression as a potentially fatal condition, which is characterised by hopelessness, suicidal thoughts, negative ruminations, poor concentration, irritability and feelings of guilt. A person suffering severe depression hence looses the ability or willingness to enjoy life, and as a result, he or she may experience disruption in sexual functioning, appetite and sleeping patterns.1 While there are other treatment methods used in the treatment of severe depression, Cognitive Behavioural Therapy (CBT) is one of the common approaches used in managing the condition. According to Evans et al.
, 2 CBT has not only demonstrated its equivalence or superiority to other depression treatments, it has also established its effectiveness in preventing depression relapse. To understand the role that CBT plays in managing severely depressed patients however, one must have a clear understanding of what exactly CBT is. Simmons and Griffiths3 state that CBT can be simply defined as a guide that helps the patient think positively. More comprehensively however, CBT is defined 3 (p5) as a “therapeutic style, which includes the psychological formulation of a problem, a collaborative relationship between the patient and the therapist, and use of aids and techniques to help the patient attain positive thoughts”. This form of goal-oriented therapy is used on the assumption that clinicians possess ideas and skills that enable them to intervene in the patient’s condition, hence helping the patient overcome the emotional difficulties accountable for his severely depressed state.3 overall, CBT works on the idea that people’s thoughts affect their feelings and actions.4,5 According to Simmons and Griffiths3, the role of CBT in the management of depression is contained in the cognitive aspect of the therapy. The cognitive aspect works on the premise that a clinician can foster behaviour change in a patient through self-instructional training.
The self-instructional training is meant to equip the patient with ways and means of pushing away negative thoughts, and reinforcing his or her emotions through helpful self-talk.3 Through CBT, a severely depressed patient learns how to access the negative thoughts that occur automatically in his or her mind when faced by a specific situation.3 For example, a depressed patient suffering from albinism may always associate his skin colour with what other people think of him. However, he may not recognise his thoughts about albinism as the trigger for his negative thoughts until a clinician helps him to be aware of the same. According to Simmons and Griffiths, 3 severely depressed patients undergoing CBT also acquire cognitive skills, which enable them to become aware of, and differentiate various emotions that they may have at different situations.
Some of the emotions prevalent in depressed patients include anger, sadness, anxiety and guilt3. Becoming aware and differentiating the diverse emotions allow the clinician and patient to establish the cause of such emotions, and hence devise effective thought processes to counter the same. Dalton and Farrington4 further note that CBT makes room for clinician-patient interaction, whereby, the two get to discuss what leads to the emotions that the patient experiences, and how long those emotions last. This is done in order to establish the exact link between the patient’s “thoughts, feelings and behaviours”.4 (p10) Branch and Wilson5 hold the opinion that often times, people (and in this case patients), know the practical and sensible approach to handle their emotional crisis. Notably however, these approaches are not always easy to enforce hence the need for CBT intervention. According to the two authors, 5 (p9) “CBT maximises on a person’s common sense and helps him or her to deliberately adopt healthy, self-enhancing thoughts on a regular basis”.
Defining the role that CBT plays in the management of severe depression cannot be comprehensive without acknowledging its educational nature. Unlike other treatment options available for severely depressed patients, CBT provides patients with a great deal of information, which is intended to help them “become their own therapists”.5(p10) According to Branch and Willson,5 CBT combines behavioural, scientific and philosophical aspects, which collectively provide patients with a comprehensive approach to overcoming their psychological problems. Using a scientific approach, the clinician educates the patient about treating their thoughts as theories or hypotheses rather than truths or facts. This enhances the patient’s ability to critically analyse his or her thoughts and rationally choosing how to behave. The philosophical approach on the other hand, starts by educating patients on how to identify and recognise personal beliefs and values that shape the way they think and act.
Through philosophical teachings contained in CBT, a patient learns how to “develop flexible, non-extreme and self-helping beliefs”. 5(p11) This means that a patient who has undergone CBT is able to adapt to the reality more easily. In addition to emphasising the role that thoughts have on a patient’s behaviours, CBT also acknowledges that environmental factors have an effect on the feelings, thoughts and actions of a person. Notably however, CBT clinicians are encouraged to take into consideration that a patient is not always in a position to change his or her environment.5 In such a case, the therapist should maintain that patients can still change their feelings and emotions in a specific environment (even though they may not be able to change the environment), by replacing unhelpful thoughts with positive ones. The behavioural aspect of CBT is emphasised through teaching severely depressed patients of the need to change their behaviours.
This is an active process that requires the patient to start by modifying his thoughts, then feelings, and finally his behaviours5. If one is lethargic and anxious for example, the clinician using CBT will encourage him to take a step-by-step approach that will lead eventually enable him confront his worries. CBT also train patients on effective ways of shifting their attention from events, people or situations that produce undesirable emotions. As such, Branch and Willson5 posit that underlying motive for every clinician using CBT to manage severe depression should be informing patients that healthy thinking can enable them live happier and more productive lives. Overall, the role of CBT in managing severely depressed patients can be summed up as the provision of a focused approach, which equips patients with the knowledge necessary to solve their behavioural and emotional problems.
For cognitive behavioural therapy to succeed however, the clinician and the patient need to work together in order to establish specific goals regarding the feelings and behaviours that the patient would like to have. This gives both the patient and the therapist specific targets to work towards. Ideally, CBT use should provide the patient with a lasting solution to the defeatist attitude that underpins depressive tendencies.
Depression. In: Hawton PM, Salkovskis J, Kirk A, Clark D, editors. Cognitive Behaviour Therapy for Psychiatric Problems. Oxford: Oxford University Press; 1989. Evans MD, Hollon D, DeRubeis RJ, Piasecki JM, Grove WM, Garvey MJ, Tuason VB.
Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry. 1992; 49(1): 802-808. Simmons J, Griffiths R. CBT for beginners. London.
Sage Publications; 2009. Dalton L, Farrington A. Getting through depression with CBT: A young person’s guide. Witney, Oxon.
Blue Stallion publications. Branch R, Willson R. Cognitive Behavioural Therapy for Dummies. West Sussex. John Wiley & Sons.