- Identify the cognitive triad typical of clients with clinical depression (one paragraph).
- Discuss the common maintenance processes of depression.
- Consider a hypothetical client experiencing major depression. Address the first 3 steps of the Course of Treatment in Chapter 12 on page 283 of your textbook for this client. For #3, include Activity Scheduling & Behavioural Activation and one additional early-stage cognitive strategy.
The Cognitive Triad Typical of Clients with Clinical Depression.
The American Psychological Association (APA) identified a number of common symptoms and variables that underlie all depressive disorders, some of which include: a loss of interest or enjoyment in some or all activities, changes in weight gain/loss along with appetite; changes in sleep patters; loss of energy; feelings of worthlessness or guiltless; poor concentration, along with suicidal thoughts and images (Kennerly et al., 2017). Conceptualized by Beck, the classical model of depression is centred on the cognitive triad that includes a pattern of negative thinking about: oneself (“I am ugly”), current and past experiences along with others and the world (“Nobody wants to date me, ever”), and the future (“I am going to be single forever”) (Blackburn, 1998; Kennerly et al., 2017). These negative automatic thoughts are triggered by stimuli and are maintained by various processing errors with a negative foundation (Blackburn, 1998).
The Common Maintenance Processes of Depression
When working with clients who are diagnosed with depression, it is important to note that these symptoms are often exacerbated and maintained by negative cognitive processes. Kennerly et al., (2017) publish common vicious cycles which includes a cycle linking the clients depressed mood with negative interpretations and biases of their symptoms, that results in a negative view of the self consisting of feelings of guilt, shame, and worthlessness. Furthermore, these negative biases and symptoms may result in reduced activities that the client previously has found pleasurable or providing a sense of achievement which may maintain their low mood.
Along with this, these depressive symptoms further result in a reduction of attempts to cope/deal with these symptoms, which leads to hopelessness and reinforces depression (kennerly et al., 2017). Additionally, a ‘viscous flower’ framework further illustrates the core problems with various maintenance processes and is useful when there are core concerns that drive multiple
maintenance processes (Kennerly et al., 2017). In terms of depression, Moorey proposed six different maintenance cycles that are common and are proposed to be the basis for ‘growing a viscous flower’ (Kennerly et al., 2017). The factors included in the cycles include: autonomic negative thinking, rumination/self-attack, withdrawal/avoidance, unhelpful behaviour(s), mood/emotions, along with motivation/physical symptoms (Kennerly et al., 2017, p. 837). With the use of these frameworks, counsellors are able to draw together the various aspects of complex issues in order to establish core problems and specific examples of how the issue illustrates itself, help client identify negative cognitions and counteract these negative biases to develop a balanced view of themselves, the world, and the future (Kennerly et al., 2017).
A Hypothetical Client Experiencing Major Depression.
Julie is a twenty-three year old college student with presenting problems of major depressive disorder. Over the past couple of months, Julie has been experiencing a depressed mood nearly everyday along with a loss of interest in activities she once found enjoyable, that provided her with pleasure and a sense of achievement. Julie often expresses feelings of shame, guilt, and worthlessness stating that she is “useless”, that she can “never do anything right”, and that she will never be able to amount to anything. Along with this, Julie has experienced major weight loss along, a decrease in appetite, and the inability to sleep nearly every night that results in fatigue, loss of energy, and the inability to think or concentrate (American Psychiatric Association, 2013). These symptoms have negatively impacted her school as she lacks the motivation to attend her college classes, complete basic assignments, and study for exams. In addition to this, Julie has expressed thoughts and images of suicide without a specific plan (American Psychiatric Association, 2013). Furthermore, Julie reveals that these symptoms cause significant distress in her life, along with an impairment in her social, professional, and everyday functioning (American Psychiatric Association, 2013).
During her early life, Julie expressed that her father left the family at a young age and has not had any contact with him throughout childhood and even now, during her young adulthood years. Along with this, Julie states that her mother was often distant growing up and spent most of her time drinking. She also concludes that her mother often disregarded her emotions, brushing them off as unimportant and deeming them as excessive. Along with this, Julie vividly remembers the times her mother punished her for expressing her emotions (e.x. crying, anger, frustration) and often ignored her pleas for attention as a child. These experiences are often defined as childhood emotional neglect and often contribute to the development of and expression of psychiatric distress such as symptoms of anxiety and depression (Spinazzola et al., 2015; Kealy et al., 2020). Furthermore, psychologically maltreated individuals have significantly higher odds of behavioural problems at home, skipping school, self-injurious behaviours, attachment issues, acute stress disorder, generalized anxiety disorder, and depression (Spinazzola et al., 2015).
Kennerly and colleagues (2017) publish that there are multiple systems within an individual that interact with each other and the individuals social, familial, cultural, and economic environment. These systems include cognitions, emotion, behaviour, and physiology (Kennerly et al., 2017). Julie experiences depressed moods followed by negative cognitive biases and symptoms (e.g. fatigue, poor concentration, etc) which contribute to her reduced activity in previously enjoyable activities. As a result, this cycle circles back to her depressed mood and the reduced coping and problem solving often leads to no positive changes, an increase in hopelessness, further deepening Julie’s depression. Furthermore, Julie’s immediate environment consisting of her emotionally distant mother along with the economic stress of school and the inability to openly discuss her symptoms with friends, leaves Julie feeling hopeless, often overthinking and ruminating in her negative cognitions.
The goal of implementing cognitive behavioural therapy (CBT) is to aid the client in identifying and taking a step back from their negative cognitions, help the client counteract these negative cognitions and to develop a balanced view, aid in restoring their activity levels to take part in activities that once provided the client with a sense of pleasure and achievement, along with increasing the clients active engagement and problem solving abilities (Kennerly et al.. 2017).
It is important to implement an activity scheduling technique as this intervention is derived from basic behavioural concepts based on the need to build up reinforcing activities that provide the client with a sense of pleasure and achievement (Kennerly et al., 2017). A weekly activity schedule (WAS) is an essential tool for motioning and managing the weekly activities of clients that includes a rating of how pleasurable and achieving the individual found that specific activity. The information provided in the WAS can provide a sense of discovery for both counsellor and client to figure out what is happening, how Julie is spending her time, and which activities provide her with pleasure and achievement. Furthermore, the WAS can be used to obtain a more accurate record of what Julie is taking part in her daily life in order to test her negative beliefs and cognitions that she is “useless” (Kennerly et al., 2017). Julie is able to use the WAS in order to plan activities that have been identified in providing her some pleasure and sense of achievement. In previous sessions, Julie expressed that she enjoys working out and going for walks with her friends, along with painting/drawing as this is a creative outlet for her to express her thoughts and emotions. With this in mind, Julie can strategically plan 30 minutes or an hour of these activities into her WAS.
In addition to implementing the WAS, early-stage cognitive strategies are implemented to distract the client from their negative cognitions, and/or change their attitude towards them (Kennerly et al., 2017). Julie often experiences rumination in her negative thoughts that often pulls her deeper into depression and her negative cognitions. The cognitive intervention of distraction can aid in reducing rumination in depression and is desired to promote a change in attitude and negative images (Kennerly et al., 2017). Furthermore, the use of distraction in CBT can include the technique of exercise, something Julie had once enjoyed. Engaging in physical exercise is useful for when an individual is preoccupied. These activities can be overt (e.g. going for a run), discreet (e.g. pelvic floor exercises), and mundane (e.g. household chores) but essentially, engaging (Kennerly et al., 2017). It is important to collaborate with Julie as these exercises must suit the client and build on their interests and strengths. As previously stated, implementing 30 minutes to an hour of daily exercise in Julie’s WAS can be highly beneficial to increasing pleasure, achievement, and slow down or hinder the vicious cycle. Prior to introducing cognitive/behavioural interventions, relapse management should be discussed and implemented as it is important to use them in difficult situations and to draw on these techniques after a setback (Kennerly et al., 2017). It is important to identify those early warning signs in order to take action before the client relapses back into their negative cognitions and behaviours.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
Blackburn, I.-M. (1998). Cognitive therapy. Comprehensive Clinical Psychology, 51–84. https://doi.org/10.1016/b0080-4270(73)00187-5
Kealy, D., Laverdière, O., Cox, D. W., & Hewitt, P. L. (2020). Childhood emotional neglect and depressive and anxiety symptoms among mental health outpatients: The mediating roles of narcissistic vulnerability and shame. Journal of Mental Health, 1–9. https://doi.org/10.1080/09638237.2020.1836557
Kennerley, H., Kirk, J., & Westbrook, D. (2017). An introduction to cognitive behaviour therapy: Skills and applications. Sage Publications Ltd.
Spinazzola, J., Hodgdon, H., Liang, L.-J. L., Ford, J. D., Layne, C. M., Pynoos, R., Briggs, E. C., Stolbach, B., & Kisiel, C. (2015). Unseen wounds. Monitor on Psychology. Retrieved December 12, 2021, from https://www.apa.org/monitor/2015/07-08/ce-corner.