4 Depression is a major public health issue with significant personal and societal costs. By 2020, depression is predicted to become the second most costly and debilitating disorder, with heart disease first (Murray & Lopez, 1996). As reviewed in Chapter 1, about 16% of the United States population suffers at any given time from a mood disorder. In the United Kingdom, nearly one in six adults will experience a type of depression at some point in their lifetime (National Institute for Health and Clinical Excellence, 2009). These numbers are exacerbated by the fact that depression is a chronic illness. Many people experience several episodes throughout their lives. Helpful and cost-effective treatments for this serious illness are needed. CBT has proved effective across the severity spectrum and may be as helpful for more severe depression as it is for less (DeRubeis et al., 2005; Fournier et al., 2009). CBT clinicians should not be shy about sharing these research findings with the public and policymakers. The high prevalence of depression and relapse has created an increased demand for improved public access to effective psychotherapy. CBGT for depression is thus a priority in community mental health settings. Because of this, I devote two chapters, 4 and 5, to a comprehensive CBGT program for depression. Other disorders in this book are limited to one chapter or a section of a chapter. CBT groups are effective for two main types of depression: major depressive disorder (MDD) and dysthymia. MDD affects about 5–9% of the population at any given time and is characterized by (a) at least 2 weeks of depressed mood most of the day, nearly every day, or (b) loss of interests or pleasure in most daily activities. According to the DSM-5 (American Psychiatric Association [APA], 2013),1 one or both of the two main symptoms must be followed by three or four of the following symptoms, amounting to a total of at least five symptoms present nearly every day: significant appetite/weight loss or increase, insomnia or hypersomnia, agitated/restless behavior or slowing in movements that is observable to others, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, indecisiveness, recurrent thoughts of death and suicide with or without a specific plan, or a suicide attempt. Depressive episodes can be categorized by severity as mild, moderate, severe, or severe with psychotic features (i.e., presence of delusions such as a belief that one is being conspired against, or hallucinations such as hearing a voice telling one to commit suicide). A major depressive episode lasting for at least 2 weeks can also be a component of other mental health disorders such as bipolar disorder or schizoaffective disorder. Dysthymia, also referred to as chronic, milder depression, affects about 3% of a population at any given time and is characterized by at least 2 years of depressed mood nearly all the time, accompanied by at least two other symptoms (similar to the ones in a major depressive episode): poor appetite, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, or feelings of hopelessness (APA, 2000). In the DSM-5 (APA, 2013), dysthymia is referred to as persistent depressive disorder. People with persistent depressive disorder must not have had symptom-free periods for more than 2 months at a time. It is noteworthy that passive suicidal ideation (e.g., believing it would not make much of a difference if one were dead) is often part of the presentation but not part of the actual diagnosis for persistent depressive disorder. It is entirely possible for a person to have had many years of dysthymia and then enter into one or more major depressive episodes. The person will then be diagnosed with persistent depressive disorder with intermittent major depressive episodes. This is sometimes referred to as “double depression.” Depression is also often accompanied by anxiety. This led the DSM-5 (APA, 2013) to include the option of adding with anxious distress to a diagnosis of MDD or persistent depressive disorder. An additional type of client is present in most CBT groups: those who do not meet criteria for either MDD or persistent depressive disorder. Some will have diagnoses of bipolar disorder (cycling between episodes of depression and mania) with mostly episodes of depression, whereas others may—or may not—have had any past episodes of depression. Although some programs will not accept people without a DSM diagnosis, the argument for prevention ought to be advanced if a history reveals significant vulnerability factors such as a pronounced, negative thinking style coupled with psychosocial stressors including divorce, loss of employment, serious financial setback, or major life transition such as retirement. People who acknowledge proneness to setting unreasonably high personal standards and castigation of themselves when falling short are good candidates for CBGT for depression. Conversely, if a depressed client in an intake assessment shows no interest in their own thinking style, denies any self-denigration, and shows no curiosity about it, another form of psychotherapy, such as IPT (briefly reviewed in Chapter 8), may be a better treatment option. It can be problematic for CBT group cohesion if one or more members of a group continue to resist the notion of dysfunctional beliefs, the pivotal part of the cognitive strategies, which takes up at least half of a standard depression group. It is thus in everyone’s best interest to screen out those clients and offer alternatives. For severely depressed clients, cognitive work in the form of addressing dysfunctional beliefs is not recommended, at least not initially (Hollon, 2011). Instead, treatment needs to first focus on behavioral activation. Although behavioral activation is a core component of the CBGT protocol outlined here, some clients with severe depression may need exclusive behavioral activation treatment before being recommended for standard CBGT with its major emphasis on cognitive interventions. All CBT protocols for depression are more or less based on Aaron Beck’s cognitive theory. Beck maintains that a particular negative and self-critical thinking style stems from a mental filter through which perceptions of oneself, one’s surroundings, and one’s future become distorted (Beck, Rush, Shaw, & Emery, 1979). One can think of this filter as a deeper cognitive structure, a schema, giving rise to daily negative commentary. Consider the mind-set of a woman wondering why her friend is not phoning her: “Why did Lisa not call me back? She’s probably trying to get out of having lunch with me, or she just wants to do it because she feels sorry for me. I think I saw her rolling her eyes to Barbara when we talked about going out for lunch.” These “thought-locks,” which cause a person to jump to a conclusion without first “checking the facts,” are the norm for depressed people entering therapy. In Beck’s model, schemas develop over time, usually beginning in early childhood, and interact with critical life events resulting in symptoms of depression. Here is how Beck describes this process: In childhood and adolescence, the depression-prone individual becomes sensitized to certain types of life situations. The traumatic situations initially responsible for embedding or reinforcing the negative attitude that comprise the depressive constellation are the prototypes of the specific stresses that may later activate these constellations. When a person is subjected to situations reminiscent of the original traumatic experiences, s/he may then become depressed. The process may be likened to conditioning in which a particular response is linked to a specific stimulus, once the chain has been formed, stimuli similar to the original stimulus may evoke the conditioned response. (Beck, 1967/1972, p. 278) Staying with the aforementioned case, the woman wondering why Lisa has not called her back may have had a painful experience of being excluded in junior high school by a group of girls she wanted to be part of. Even though she has had a positive university experience including some solid friendships with like-minded people, the original trauma is more easily activated than in someone who has not had such an experience of feeling ostracized. From Beck’s theory, we learn what a huge role is played by our thinking or what we say to ourselves. So, it is important to ensure that depressed people interested in a CBT group for depression are prepared for addressing their thinking style. We also see that any critique of CBT as a “superficial therapy lacking tradition” is unfounded. Even Shakespeare anticipated the coming of CBT when his Hamlet, caught in a chilling family drama, proclaimed: “For there is nothing either good or bad, but thinking makes it so” (Hamlet, Act 2, Scene 2). The Greek Stoic philosopher Epictetus (AD 55–135) also contributed to the philosophical underpinning of CBT with his famous saying: “We are not disturbed by what happens to us, but by our thoughts about what happens to us.” These quotes are inspiring but are not meant to place absolute value on thinking over the events themselves. Imagine how that could be manipulated to minimize real tragedies such as abuse, natural disasters, loss of loved ones, and social injustice. CBT takes very seriously what happened to a person throughout their childhood and adolescence and especially their perceptions and interpretations of events. Connecting present struggles back to their possible origins is a significant part of the work in a CBT group. Not only is this tremendously helpful for the individual, it also promotes a more empathic stance toward fellow group members. Clinicians who routinely work with depressed clients, whether individually or in group, are aware of how “self-absorbed” such clients can come across. People with depression are usually aware of this too, which intensifies the vicious cycle of self-punishing thoughts: “I can understand why my girlfriend left me. She’s right about my self-absorption. Some days I barely have the energy to ask about her day, let alone suggest we do something she enjoys on the weekend.” Part of the psychoeducation in CBT for depression involves helping people understand that their character is not one of intense self-absorption (as it is in some personality disorders) but that the clinical manifestation of depression involves a lack of ability to get “out of one’s own bubble” and engage more empathically with others. The opportunity for this more other-focused way of relating is naturally one of the many benefits of a group format for depression. It is indeed rewarding to notice the positive increase in feelings and self-evaluations when group members slowly show more care and interest in each other. It is not uncommon to hear people voice the relief they feel from breaking out of their self-preoccupation. Similar to individual CBT, there are four main components of a comprehensive CBGT protocol for depression: (a) education about depression and the cognitive model; (b) behavioral strategies, including self-monitoring of daily activities and goal setting; (c) cognitive strategies, including identifying, challenging, and replacing negative thinking; and (d) relapse prevention strategies. Appendix A offers a sample outline of a 12-session, 2-hour weekly treatment protocol for group CBT. It is adapted from two key sources on individual CBT for depression: the depression chapter from Cognitive Behaviour Therapy for Psychiatric Problems (Fennell, 1989) and the Mind over Mood protocol by Greenberger and Padesky (1995). The adapted protocol is based on groups with 6–10 members who are suffering from depression ranging from subthreshold to moderately severe. Most are referred by their family doctors, and some have attempted a self-help program with telephone coaching but failed to make sufficient improvements. Acceptance into such a group is based on ability to attend regularly, that is, sufficient energy to arrive on time and stay alert during the session and commit to homework between sessions. If there is a history of active or passive suicidal behavior, this needs to be monitored and additional support put in place. For the group to be helpful, all members must have depression as their primary problem. Other problems such as an anxiety disorder can be present so long as the client knows that this issue will not be specifically addressed in the group. All group members have had a prior intake assessment as well as a pregroup orientation session (Chapter 6 outlines the assessment and orientation process). This orientation focuses on insight into critical thinking patterns and expectations for group participation. Clients are told that the group is primarily educational with the facilitators presenting new information and exercises every week but that ability and willingness to offer and receive feedback from other group members is expected. This creates an opportunity to discuss the level of self-disclosure required for the group, as well as nervousness about interacting with other depressed people. The first two to three sessions are devoted to education about depression and the CBT approach. The initial session includes introductory go-rounds and review of ground rules as outlined in Chapter 1. This is followed by presenting the CBT triangle (see Figure 4.1) and discussing the connection between thoughts, moods, and behaviors. One therapist sketches the triangle on a board or uses other means of visual display. The other therapist explains how the connection is driven by the catalytic impact thoughts have on feelings and behaviors. It is, however, critical to dispel any notion of thoughts causing depression. Thoughts do not cause depression, but are associated with depression. Figure 4.1 CBT triangle. Not wanting to put anybody on the spot in the first session, the therapists use hypothetical examples of how a certain thought (e.g., Lisa is trying to get out of going for lunch with me) influences how one feels (e.g., sad, upset) and behaves (e.g., goes to bed early instead of out for a walk). A contrasting healthy thought response to the same scenario is also derived from prompting the group. The group usually agrees that a person who was not depressed would likely think: “Something is going on for Lisa and she has forgotten our lunch.” The group is usually quick to suggest associated feelings of care and concern and a behavior involving making a note to call Lisa tomorrow and carry on with what one had planned to do. The first group session ends with showing a shorter movie based on personal stories of people recovering from depression. The postmovie discussion increases motivation and positive expectations (recommendations for movies are given in Chapter 6). Depressed clients invariably ask about causes of depression, which is addressed in session 2. While many are convinced they have a biochemical imbalance, most are open to other influences as well. Therapists start this discussion with a statement about all mental health issues being multiply determined and best to avoid oversimplistic beliefs about causality. We talk about genetics, innate temperament, biochemistry, early childhood environment, salient life stressors, and subjective experiences of what is stressful. During this discussion, we refer the group to a handout in their folder (Chapter 1 described the use of folders): the Cognitive Model of Depression (Appendix B). One therapist takes the lead in walking the group through the model explaining that CBT therapists tend to understand depression as both a thinking disorder and a mood disorder and that the way we think has profound impact on our feelings and behaviors. The cotherapist may sketch, similar to the first session, the triangle of thoughts–moods–behaviors. We continue with essentially a mini-lecture on Beck’s cognitive model. We use the example in the Cognitive Model of Depression (Appendix B) but encourage clients to insert experiences and examples of dysfunctional thinking from their own life. In fact, we provide them with a “blank” cognitive model for creating their own cognitive model for better understanding their depression (Appendix B). In explaining the cognitive model, we emphasize that early life experiences affect most of us. These may include being unfavorably compared to a sibling, losing contact with a parent due to death or divorce, being bullied, or being unfairly treated by a teacher and of course more extreme experiences of physical or sexual abuse. Because the child’s brain is plastic and easily influenced, these critical experiences can lead to personalized beliefs about “not being good enough,” “not as smart as others,” or “not lovable.” We call these beliefs dysfunctional assumptions (assumptions can in this model be considered equivalent to schemas or core beliefs). For many of us, life goes on and we are not that aware of these assumptions. They are in a sense dormant. However, when a critical event happens—and very few people escape those—such as significant conflicts at work, relationship breakups, or serious problems with a child, these assumptions get activated and influence how we cope with the crisis. For example, someone with an assumption of “I’m not good enough” will tend to think that a work or marriage conflict is mostly, or even entirely, their fault. In contrast, people without dysfunctional assumptions or only a modicum thereof (some self-criticalness is healthy, lest we become narcissistic) would understand that all relationships are a two-way street and that one partner taking all the blame may interfere with productive negotiation and compromise. At this point, we see a lot of nodding in the room and often crying. Therapists new to CBGT for depression frequently ask the primary therapist or their supervisor about how to handle crying in the group. It is a good question and more senior therapists see the discomfort experienced by the junior therapists when one or more members cry in their group. It is best just to let the crying happen without much reaction on the part of the therapists. Other group members tend to beat the therapists to passing on the Kleenex box, or offer their own tissue. Therapists may reflect something like “we appreciate how difficult it can be to reflect back on your life” or “your sadness makes sense; we appreciate you feel comfortable enough here to express it,” or “this group can be a helpful place to share some feelings you may not want your close family and friends to be a part of.” We continue by explaining that when these dysfunctional assumptions are not addressed therapeutically, they tend to give rise to an ongoing negative, self-critical commentary: the negative automatic thoughts in Beck’s language. Clients often talk about this feeling like a tape loop playing in their head or as if some gremlin was sitting on their shoulder commenting critically on every move they make. Some people are able to connect this “voice”2 of negative automatic thoughts to an actual person of their past, a parent or parental figure, but often there is no specific person. One group therapist coined his own CBT technique of the “eviction notice,” which proved quite successful in encouraging group members to “evict” the self-critical voices from their mind. If the negative automatic thoughts are not reigned in, they easily lead to a host of depression symptoms. Each symptom category (motivational, somatic/bodily, cognitive, behavioral, and affective) is reviewed in a group discussion. The difference between MDD and persistent depressive disorder (dysthymia) is also reviewed at this point. Group members often do not know their diagnosis, but only that they are depressed according to their own understanding, or that of their family doctor. If time permits, group members are invited to reflect on the cognitive model and insert examples from their own life stories. This is voluntary and not assigned as formal homework, but in most groups, clients willingly share their stories and it promotes group cohesion as people listen empathically and relate to each other’s stories. We allow this life review and schema insight development to carry over into part of the next session, session 3, but then make it clear that we will be moving from the past to the present. We explain that awareness of the past will continue to inform the rest of the sessions in the group but that we are not going to be reviewing past events in detail. Occasionally, a few people become very interested in their family of origin. This can be a feature of their depression in the form of “searching for a root cause.” In that case, it has an unproductive ruminative quality, which usually diminishes as the depression improves. Sometimes, people who recover from their depression continue to be interested in understanding their past better, and it is appropriate to suggest they become connected with a more psychodynamic form of therapy, if available, after the CBT depression group is over. Although Beck’s cognitive model emphasizes the central role that distorted cognitions play in the development and maintenance of depression, CBGT therapists tend to first target behavioral activation. It is our experience that an increase in energy and the improved self-confidence that comes from accomplishing tasks make it easier to fully engage with the cognitive strategies. Cognitive work involving challenging one’s thinking (which will be presented in Chapter 5) can be a strain for a person with compromised resources of the mind (such as difficulty concentrating and/or entertaining multiple perspectives on an issue), so any increase in energy and feelings of self-efficacy helps. Also, the behavioral tasks do not require a deeper examination of one’s thinking style and are thus easier to engage with in the beginning of a group when everything and everyone is unfamiliar. The rest of this chapter focuses on behavioral interventions as well the importance of identifying emotions. Therapists begin the behavioral work in session 3 by explaining that in depression, motivation works backward, that is, the less we do, the more tired and depleted of energy we feel. We deliberately emphasize this as a symptom of depression and encourage people to reflect on why it is incorrect to label themselves “lazy” or “boring.” Lack of energy and believing that one cannot do very much without becoming exhausted is probably a hallmark feature of depression. It is crucial to address it in the early part of CBT, including how it can be almost shocking to realize that beliefs about, for example, everyone needing 10 hours of sleep are incorrect. Therapists then stimulate a group discussion of which activities people used to enjoy, have stopped doing, and would like to resume. For group members who are at a loss for which activities give them meaning and joy, therapists can create a handout similar to the one in Appendix C “10 Things I like to Do (Or Used to Like to Do).” Depressed people, by diagnostic definition, do not derive much enjoyment from their days and often feel inadequate as an employee—if working—or as a spouse, parent, or friend. Getting a sense of how group members spend their days is helpful. Self-monitoring is a classic CBT technique, and the Daily Activity Rating Scale (Fennell, 1989; Greenberger & Padesky, 1995) is a valuable behavioral intervention. We assign it as homework between sessions 3 and 4. This scale asks people to complete a log of what they do hour to hour—using only a few words—in a given day while also rating their feelings of pleasure and mastery on a scale of 0–10. Group therapists can easily make such a log listing each day, broken down into 1-hour segments. We introduce it as an exercise in learning more about oneself. It is in some ways a lot to ask, and it is rare that all group members complete the entire week; however, we keep using it because group members like it and find it helpful. In the group following this homework, the facilitators encourage members to express what they learned about themselves and to offer feedback to each other. For example, one woman was surprised at how good she was at getting her children up and to school (mastery was rated 8/10) but also at how little pleasure this gave her (pleasure rated 4/10). She used this realization to set a goal of getting up 30 minutes earlier and doing a meditation practice for 15 minutes while the house was quiet with everybody else sleeping. Starting the day with some calm moments for herself allowed her to better enjoy the morning routine with her children. Humor usually also gets shared during self-monitoring review. There is almost always one person who will exclaim: “I’ve mastered the art of sleeping and am very good at lying on the couch—10/10!” We encourage people to be brutally honest about their daily activities including sleeping, watching TV, or doing “nothing.” When people feel safe and supported in the group, this kind of honesty is rarely a problem. The results from the self-monitoring become a handy stepping stone for setting more formal goals, often related to increasing pleasurable activities. Goal setting is pivotal in CBT. This stems from the problem with doing too little when one is depressed. Avoiding pleasurable and other kinds of activities such as necessary ones (e.g., scheduling medical appointments or buying groceries) deprives people with depression of opportunities for positive reinforcement. The avoidance behavior becomes negatively reinforcing. In CBT terms, a behavior is negatively reinforced if it increases because it is followed by the absence of an anticipated aversive event. In depression, the anticipated aversive event could be a fear that one will not be able to complete a task properly, that one will not enjoy starting a new leisure activity, or that other people will be rejecting. Thus, by staying safely at home on the couch, one can be certain none of these feared scenarios will actualize. Committing to goals for doing more is a critical step in treating depression. Articulating goals and taking steps to accomplish them create momentum in people’s lives and offer a way to measure progress. In session 3 or 4, therapists introduce the art and skill of goal setting. One way to do this is by using the concept of specific and achievable SMART goals, based on the acronym SMART (Paterson, Alden, & Koch, 2006): For more in-depth coverage of goal setting, the excellent CBT-based Changeways program offers many suggestions (Paterson et al., 2006). In addition to asking each member to set a goal they estimate to have a 95% chance of completion, they indicate a specific time to begin and identify any anticipated obstacles. All of this is written down on a goal sheet handout (Greenberger & Padesky, 1995). Anticipating barriers allows the group to show they are beginning to know each other and stimulates productive interactions. Ensuring that all members have a SMART goal plan for their homework maximizes the chance of the goals being accomplished. Therapists should make a point of encouraging group members to support one another. The following dialogue involves a missed opportunity for the therapists to work with the process factor of using group members as role models—through imparting of information, to use Yalom’s language. The therapists are not doing anything particularly wrong and they show empathy for Wendy, but the group is not engaged and Wendy is deprived of learning from others. The example of Wendy is followed by a suggestion for how therapists could include the whole group. First, the missed opportunity. Therapist:
CBGT for Depression: Psychoeducation and Behavioral Interventions
The Diagnoses of Depression
Treatment Protocols Informed by Beck’s Cognitive Model of Depression
An Example of a CBGT Depression Protocol
Psychoeducation
Behavioral Interventions
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CBGT for Depression
Wendy, what goal for the week did you set?
