Typical Cognitive Triad in Clients with Clinical Depression
Three core aspects of thought schemas impacted by clinical depression, known as "depressive cognitive triad," introduced by Beck, are negative thinking patterns about oneself accompanied with guilt feeling; seeing the external world with discriminatory consideration of negativity and the prospect with negativity and desperateness (Kennerley et al., 2017). Souls with depression tend to perceive themselves as innately dysfunctional, excessively liable for adverse events, and prone to self-blame (Beck & Beck, 2020). The person suffering from depression, regardless of the cause, is exaggeratedly focused on unfavourable external circumstances and negatively processes recent and past events (Sokol & Fox, 2019). Additionally, depressed individuals are more likely to have an unenthusiastic view of their future, believing that they can do nothing to change it.
Common Maintenance Processes of Depression
Several fundamental maintaining cycles have been proposed to be implicated in depression (Kennerley et al., 2017). The first would be that depressed people are more likely to interpret depression symptoms as feelings of failure, reinforcing their negative self-perception, which is part of the cognitive triangle described above. This might show up as habitual negative thoughts that go unquestioned, leading to rumination, exacerbating symptoms and negative self-perceptions. Furthermore, their poor mood prevents them from engaging in pleasurable activities, leaving them imprisoned doing things that make them feel even worse. They may, for example, lack the energy to do something that would excite them, such as go for a stroll or chat with a close friend, and instead choose to remain in bed. Finally, depression might affect their problem-solving skills because they may doubt their efforts to improve their mood by believing that such actions are ineffective (Sperry & Sperry, 2017). Problem-solving is thus ignored or tried with only half-heartedness, perhaps leading to further issues and a sense of despair. All three of these processes, seeing sadness as self-failure, avoiding delight activities, and feeling helpless to deal with the outside world, all are factors contributing to a person's depression cycle (Kennerley et al., 2017).
Treatment Course for Depression Applying CBT
Hypothetical Client Presenting with Depression
Donya, a 29-year-old, identifies herself as a female and seeks counselling regarding recent difficulties in her life. She claims about her "downness," "not eating at all," and "not sleeping at all" during last weeks after her fiancé's' 3-day trip to Mexico a month ago. She feels not being loved, loneliness, worthlessness criticizing herself not being physically attractive enough to her partner as she feels she is "so tiny and looks like an assembled skeleton." Therefore, she believes her mate always looks around to see more attractive, nicer-looking girls, while her partner rejects all these statements. She weeps and continues worrying about the same infidelity his father had done when she was a child resulting in acting her mother in the same way and their divorce and her starting point of loneliness finally.
First Step: Identifying an Initial Targeted Problem list
Donya is not going to work and stays home without relating to others, does not eat well as she lost some weight, without doing any exercise. While withdrawing from them exacerbates her sadness, participating in these three activities may help to alleviate her feelings of sorrow. She discovers herself trapped in a round of contemplation in which her reflections center on losing her partner and the resulting aloneness. She is further frustrated because she thinks her partner does not understand how intense these pains are or how horrible she looks. Furthermore, her parent's divorce, because of their infidelity to each other while she was eight years old, can contribute to her present feeling of being left alone and sad. Her current condition proposes that her engagement in three domains of behaviours is beneficial to her: increasing activity, preparing food, and finally going back to work. Concurrently, opposing the idea that she has no one to share her life with other than her partner or won't attract her partner anymore can result in recovering feelings. The first objective inventory needs sweeping taking care and adaptable, updated with modifications as the therapy progresses.
Second Step: Case Formulation
Taking an empathetic and warm approach to her issues would allow a solid therapeutic relationship to flourish and enable her to trust the process (Okamoto et al., 2019). During the first sessions, it would be critical to elucidate to Donya about her cognitive triad of depression, her unhelpful automatic thoughts and how its maintaining effect intensifies her depressed feelings. We should immediately explain how CBT might disrupt these maintenance processes, resulting in a better interpretation of herself, the world around her, and the upcoming. When looking closely at how her parents' divorce had happened and impacted her life, we must be collaboratively careful not to generalize it overly. Deploying the principle of "here and now," we should precisely determine what her parents' infidelity is doing to her right now and how she can prevent this persistent pain from inhibiting her. Donya experiences a great deal of depression due to the excessive thoughts she has about her disproportionate body image or a possibility of her partners' infidelity in the future, even though he adores her body and actively conveys his love for her.
Sharing Donya's case formulation permits further discussions, encourages feedback for change, and empowers her to identify her road map of issues. It might help her realize that individuals in her condition can have the same range of feelings. The divorce of parents at an early age is considered to be a risk factor for depression in later life (Bohman et al., 2017). A history of depression in her mother also predisposes her further to having sad feelings, increasing her risk of being depressed later on (Boland et al., 2021). Seven times increase of global depression rate with COVID-19 outbreak, mentioned in the meta-analysis of Bueno-Notivol et al. (2021), which has affected her life too, could be a facilitator to her depression. As a final topic, her recent absence from work may cause her to question her productivity, so gathering all these factors could likely leave most individuals feeling hopeless.
Third Step: Proposal for Symptom Reduction
Incorporating the Weekly Activity Schedule (WAS) (Kennerley et al., 2017) can benefit Donya by gaining essential materials regarding how the amount of time she passes being ruminating or inactive. She can learn more about how many enjoyable, meaningful, or satisfying activities she engages in with WAS. Once she has completed a WAS that details her schedule, we would work together to introduce progressive activities that could help reactivate beneficial behaviours and lessen ruminations. Ideally, the plan would include some mild practice, such as walking for 15 minutes when she notices her ruminative thoughts popping up. The WAS may consist of another activity, such as committing to making one small meal per day. Besides, discovering how she relates to her partner or social contacts can be helpful to her to feel more supported. Imagining returning to work and the consequent possible outcome of going back to work can benefit her. Discussing why she feels she may be humiliated because of her body shape or how developing a respectful relationship with colleagues can potentiate her relationship abilities and self-esteem, noted in her WAS, would be beneficial. This decision to go and enhance/increase the interaction will result in her feeling sure that she will have the support she needs helping her to combat her feelings of loneliness.
Studies on individuals affected by COVID-19 reveal that positing Self-compassion can enhance cognitive restructuring in depressed individuals (Jansen, 2021). Recording with her permission, an exercise of self-compassion would benefit her to improve the CBT process and triumph at her lack of confidence and excessive judgment. Focusing on respecting her flawless body by this technique and noting how she feels before, during, and after finishing them could enhance her self-respect. If this routine proves successful, it can be added to her WAS during the times of day when she feels depressed and right before she begins an introduction to an activity.
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Bohman, H., Låftman, S.B., Päären, A. et al. Parental separation in childhood as a risk factor for depression in adulthood: a community-based study of adolescents screened for depression and followed up after 15 years. BMC Psychiatry 17, 117 (2017). https://doi.org/10.1186/s12888-017-1252-z
Boland, R. J., Verduin, M. L., Ruiz, P., Shah, A., & Sadock, B. J. (2021). Kaplan & Sadock's synopsis of psychiatry. Wolters Kluwer.
Bueno-Notivol, J., Gracia-García, P., Olaya, B., Lasheras, I., López-Antón, R., & Santabárbara, J. (2021). Prevalence of depression during the COVID-19 outbreak: A meta-analysis of community-based studies. International Journal of Clinical and Health Psychology, 21(1), 100196. https://doi.org/10.1016/j.ijchp.2020.07.007
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Okamoto, A., Dattilio, F. M., Dobson, K. S., & Kazantzis, N. (2019). The therapeutic relationship in cognitive–behavioral therapy: Essential features and common challenges. Practice Innovations, 4(2), 112–123. https://doi.org/10.1037/pri0000088
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