Cognitive Theory of Depression
Introduction
Depression has been traditionally viewed as an affective disorder, and disordered mood is considered the cardinal symptom, responsible for the patient’s behavioral, cognitive, and psychological deficits. The last chapter described how most research has concentrated on finding either a biological or psychological cause of depression. Because this research approach is not integrative, it fails to recognize the subtle psychological processes that may cause and maintain the disorder. To break away from this tradition, Aaron Beck has concentrated on the behavioral aspects of depression and has attempted to move beyond description to explain the development and maintenance of depression. Specifically, Beck has emphasized the role of distorted information processing in the pathogenesis of depression. His goal was to develop a theory of depression that fits the patient’s behavior, rather than making the patient’s behavior fit his theory. He focused on the depressed person’s internal world, to understand how he perceives and organizes information and how these formulations affect his symptoms. While positing his cognitive theory of depression, Beck developed a revolutionary new approach (cognitive therapy) to the treatment of depression. Although many cognitive theories of depression exist, this book focuses on Beck’s theory because it has generated substantial empirical research on the psychopathology and psychological treatment of depression. This chapter provides a detailed description of Beck’s theory of depression, then critically examines the strengths and limitations of cognitive therapy.
Beck’s Cognitive Theory of Depression
According to Beck (1967), the most salient psychological symptom of depression is the profoundly altered thinking or cognition. From his extensive clinical experience with treatment of depressive conditions, drawing specifically from his observations of the content and form of depressed patients’ dreams and verbalizations, Beck noted that clinically depressed individuals characteristically engage in a negative evaluation of themselves, their environment, and the future. They tend to be constantly preoccupied with these negative thoughts in an almost stereotypic fashion, irrespective of contrary evidence. Such negative thinking is not simply random, but forms a habitual pattern of reference to irrational assumptions or faulty cause-effect relationship that invariably involves inadequate reality testing. These observations led Beck to postulate the hypothesis that the depressed
person’s cognition is primary in the etiology and manifestation of the symptoms of depression. His theory does not state that faulty or negative cognitions are the causes of depression; it simply asserts that such cognitive activity is a primary determinant of the affective and behavioral components of depression.
person’s cognition is primary in the etiology and manifestation of the symptoms of depression. His theory does not state that faulty or negative cognitions are the causes of depression; it simply asserts that such cognitive activity is a primary determinant of the affective and behavioral components of depression.
During the past 30 years, Beck’s theory has become more complex and less purist; that is, other cognitive theories of depression (e.g., hopelessness theory of depression) have evolved and, consequently, some aspects of these theories have been integrated with Beck’s theory. Moreover, new developments have occurred in general theories of psychopathology. For example, the diathesis-stress or biopsychosocial model of mental illness has become more widely acceptable, and this has been embraced by Beck. Within the context of these developments, Beck’s current theory of depression is based on four assumptions (Kuyken, Watkins, & Beck, 2005):
Depression is a biopsychosocial disorder.
Maladaptive beliefs originate from childhood experiences.
Maladaptive beliefs are dormant or unconscious, activated by stressors.
Maladaptive beliefs interact with precipitating factors to produce depressive symptoms.
The rest of this chapter discusses the basic components of Beck’s theory of depression and examines the validity of these assumptions. Because more than 20 therapies are called “cognitive” or “cognitive-behavioral,” an explanation to specify what is meant by cognitive therapy is in order. In this book, cognitive behavior therapy (CBT) refers to the theory, therapy, and conceptual models developed by Beck and his associates (Beck, 1976; Beck, Rush, et al., 1979). Although the therapy is called “cognitive,” its emphasis is on the interaction among five elements: biology, affect, behavior, cognition, and the environment (including developmental history and culture). Because Beck paid close attention to the impact of thinking on affect, behavior, biology, and the experience of the environment, the therapy is called “cognitive.” Unfortunately, CBT carries several misunderstandings:
Cognition causes affect and/or behavior.
Many therapists and writers believe the cognitive models of psychological disorders attribute causation to thinking. This is a myth. CBT considers thoughts, feelings, behaviors, biology, and the environment to be interactive and capable of influencing each other. Thoughts are emphasized because Beck’s research demonstrated that dysfunctional thinking can often serve to maintain negative affect. Moreover, extensive empirical evidence suggests that changes in thinking can lead to changes in affect and/or behavior. For these reasons, thoughts are seen as a key target for intervention.
CBT is purely cognitive.
Although CBT emphasizes the importance of cognition in therapy, close attention is also paid to affect and behavior. Beck, et al. (1979) has highlighted the importance of feelings in cognitive therapy and, more recently, Beck (1991) stated that CBT cannot be conducted in the absence of affect.
CBT is superficial.
Some critics have charged that CBT is superficial because it focuses on symptomatic changes. This is not accurate. Although CBT emphasizes here-and-now problems, and teaches patients methods for resolving current problems and sources of distress, the therapy operates at three levels: automatic thoughts, underlying assumptions, and schemas. Automatic or surface thoughts are ideas, beliefs, and images related to specific situations that people have each moment (e.g., “My husband did not call, he doesn’t really care”). Underlying assumptions are deeper levels of thinking, consisting of conditional rules and cross-situational beliefs (e.g., “You can’t rely on men”). Our perceptions are organized by these rules, and they form the basis for automatic thoughts. Finally, schemas are core beliefs, and they consist of inflexible unconditional beliefs (e.g., “No one really cares for me”). The main goal in CBT is to identify and restructure deeper core beliefs.
CBT is bullying.
Because patients are encouraged to confront their dysfunctional thinking, the therapist is never disrespectful of the patient. On the contrary, CBT is considered to be “collaborative empiricism” (Beck, et al., 1979). CBT seeks to form a partnership between the therapist and the patient as they work together collaboratively to understand and solve the patient’s problems. Data are collected in an empirical manner to evaluate the evidence for and against dysfunctional and functional beliefs.
Tripartite Theory of Depressive Cognition
Beck has identified three major clinical features of cognition in depression: (1) the cognitive triad, (2) negative premises and self-schemas, and (3) faulty information processing. The essential components of these cognitive features are briefly described here (for a fuller exposition of these concepts see Beck, et al., 1979).
The Cognitive Triad
The cognitive triad consists of three major dysfunctional cognitive patterns that induce depressed patients to regard themselves, their experiences, and their future in a very negative manner. Beck (1987) considers the cognitive triad to be an intrinsic part of the depressive experience, and at least one aspect of the triad appears to be elevated during a depressive episode.
The first pattern of the cognitive triad revolves around the patient’s negative view of himself. He regards himself as a failure and as being defective, deprived, inadequate, undesirable, and worthless. He believes that his depression and suffering are caused by some underlying defects within himself and, because of these personal defects, he will never be able to lead a “normal” and happy life, and will always be rejected and disliked by others. Hence he perceives himself as worthless and incapable of achieving happiness.
The second component of the cognitive triad relates to negative view of the world. This consists of the tendency of the depressed patient to view the world as hostile, demanding, and obstructive, and thus making it difficult for him to reach his goals in life. Any upset or frustration caused by the interaction with the animate or inanimate environment is seen as defeat or deprivation.
According to Haaga, Dyck, and Ernst (1991), the negative view of the world does not represent the actual state of the world, but one’s personal idiosyncratic view of the world.
According to Haaga, Dyck, and Ernst (1991), the negative view of the world does not represent the actual state of the world, but one’s personal idiosyncratic view of the world.
The third component of the cognitive triad consists of a negative view of the future. Depressed patients believe their current suffering, hardship, failure, and deprivation will continue endlessly. Therefore, they anticipate failure in any immediate or future task, leading to a sense of passivity, inertia, and sense of hopelessness.
Other cardinal signs and symptoms of the depressive syndrome are regarded as consequences of the activation of this negative cognitive triad. For example, if a patient erroneously believes that he is a social outcast, then he will feel sad and withdrawn; he will incorrectly believe that he will be disliked or hated and unaccepted by others. This eventually leads to actual feelings of rejection–sadness and loneliness–which are the affective components of depression. The motivational symptoms, such as paralysis of the will, escape and avoidance, wishes, and the like are seen to result from the person’s sense of pessimism and hopelessness. In this example, since the person expects a negative outcome (rejection), he will refrain from initiating social contacts, thus increasing his sense of pessimism and hopelessness. Occasionally, the will may become so crippled that the patient contemplates suicide. According to Beck, et al. (1979), suicidal wishes represent an extreme expression of the desire to escape from what appears to be an insoluble problem or an unbearable situation. These feelings result in the depressed person seeing himself as worthless and a burden; consequently he believes that everyone, including himself, will be better off if he is dead.
Increased dependency can also be explained as a consequence of negative cognitions. Because depressed persons regard themselves as incompetent and useless, and because they view the world as presenting insurmountable difficulties, they anticipate failure even in normal tasks. Thus, they feel helpless and need to seek help and reassurance from others, whom they consider more competent and capable than themselves.
Physical symptoms can also be explained as consequences of the negative cognitive process. If patients firmly believe that they are doomed to fail in all efforts, then they are likely to become apathetic. This sense of futility in the future can lead to low energy and inhibition, ultimately resulting in psychomotor retardation.
The negative view of the self and the negative view of the future have been found to be associated with suicide risk (Weishaar & Beck, 1992). Beck found hopelessness or the extreme negative view of the future to be the key psychological factors in suicidality. Hopelessness can be defined as a stable schema incorporating negative expectancies. Beck and his colleagues (Beck, Weissman, Lester, & Trexler, 1974; Beck, Steer, Kovacs, & Garrison, 1985; Beck, Brown, Berchick, Stewart, & Steer, 1990) developed the Beck Hopelessness Scale and, through longitudinal research, substantiated the association between hopelessness and suicide risk. They demonstrated the relationship between high levels of hopelessness and suicidal intent. Beck’s research in the field of suicide is considered to be one of his most important theoretical and clinical contributions. His conceptualization of suicidality in
terms of hopelessness and cognitive distortions provides practical strategies for dealing with suicidal patients.
terms of hopelessness and cognitive distortions provides practical strategies for dealing with suicidal patients.
Negative Premises and Negative Self-Schemas
The second major ingredient of Beck’s theory consists of the concepts of premises and self-schemas, which he uses to integrate his theory and to explain why some people develop clinical depression and others do not, given the same internal and external event. These concepts also help explain why a depressed patient continues to maintain her pain-inducing and self-defeating attitudes despite objective evidence or positive encounters in her life. These concepts, by virtue of being hypothetical constructs, introduce a certain weakness to Beck’s theory, although they can be operationalized and indirectly tested.
Premises are implicit or explicit statement of fact that form the basis or cornerstone of an argument, conclusion, evaluation, or problem-solving strategy. From his extensive observation of depressed patients’ verbalizations, such as persistent and indiscriminate use of “should” or “must” statements (e.g., “I should be punished”; “I must never fail”), stereotypic conclusions (“It’s my fault”), and repeated themes (“I can never succeed”; “I’ll never be right”) irrespective of the nature of the stimuli, Beck has extrapolated that depressogenic premises or assumptions underlie the patients’ negative evaluations.
Negative self-schemas or dysfunctional core beliefs are learned through such negative childhood experiences as rejection, neglect, abandonment, or abuse. Neisser (1967) defines a schema as a relatively enduring structure that functions like a template to active screen, code, categorize, and evaluate incoming information and prior experiences. It consists of bits of information, conclusions, and silent assumptions or premises. Existent self-schemas are highly personalized, and they determine how an individual will structure different experiences. Depressogenic schemas often contain themes of rejection, abandonment, deprivation, defeat, loss, or worthlessness.
Dysfunctional schemas are latent during stable or less stressful times, but can be reactivated by negative experiences that resemble the conditions under which the original beliefs evolved. The response of a person is, therefore, not determined by the event per se, but by the activation of the underlying self-schema. Beck postulates that the activation of latent negative self-schemas are responsible for the depressive states. In his model, a schema serves the dual function of acting as a template or sensor for the selective entry or alteration of incoming stimulation, and for maintaining the internal integrity and consistency of cognitive experience over time by censoring input incongruent to the template.
In depression, the patient’s conceptualization of specific situations is distorted to fit the prepotent dysfunctional (negative) schemas. In other words, the active operation of these idiosyncratic schemas interferes with the congruent matching of an appropriate schema to a particular stimulus. Beck, et al. (1979) maintain that, as these idiosyncratic schemas progressively become more active, they gradually generalize to a wider and often unrelated set of stimuli. Consequently, the patient loses much of his voluntary control over his thinking processes and is unable to
invoke other more appropriate schemas (this cognitive process is described as a form of negative self-hypnosis in Chapter 4). The repetitive and chronic nature of depressive cognitions and associated symptomatology is attributed to the pervasive influence of negative self-schemas. The depressive syndrome, including the motivational, behavioral, motor, and vegetative symptoms, is believed to be triggered by the activation of this constellation of negative cognitions. The noncognitive components of the depressive syndrome are thus considered secondary to and, to some extent, maintained by the activation of negative cognitive schemas.
invoke other more appropriate schemas (this cognitive process is described as a form of negative self-hypnosis in Chapter 4). The repetitive and chronic nature of depressive cognitions and associated symptomatology is attributed to the pervasive influence of negative self-schemas. The depressive syndrome, including the motivational, behavioral, motor, and vegetative symptoms, is believed to be triggered by the activation of this constellation of negative cognitions. The noncognitive components of the depressive syndrome are thus considered secondary to and, to some extent, maintained by the activation of negative cognitive schemas.
Faulty Information Processing
Faulty information processing or cognitive errors are distorted interpretations of events or situations used by depressed persons to maintain their belief in the validity of their negative self-schemas, despite the presence of contradictory evidence. Beck (1967) has delineated a number of systematic errors of thinking, which depressed patients use to maintain their stereotypic negative conclusions. Burns (1999) has adapted the earlier work by Beck, extending Beck’s original postulates to ten systematic errors of thinking or cognitive distortions commonly made by depressed individuals (see Table 2.1). These cognitive distortions are autonomous, plausible, and idiosyncratic; hence, they are referred to as “automatic thoughts” (the concept of negative self-hypnosis discussed in Chapter 4 is very akin to this process).
Empiric Evidence for Beck’s Theory of Depression
Beck’s cognitive theory has generated several testable hypotheses about clinical depression. The empirical evidence for some of the key hypotheses is summarized in this section (for reviews, see Hass & Fitzgibbon, 1989;Haaga, Dyck, & Ernst, 1991; and Solomon & Haaga, 2004).
Depressed Patients Have a Negative Self-Schema
Beck’s (1967) cognitive theory assumes that a depressed patient’s perception, registration, organization, and recall of incoming information are influenced by negative self-schemas. According to this theory, it is hypothesized that depressed persons would show a bias toward the perception and recall of negative-valence information regarding the self. Haaga, Dyck, and Ernst (1991), from their review of the hypothesis that depressed patients have more negative thoughts than do nondepressed people, conclude that depressed patients have more negative cognitions than nondepressed people. These findings support the hypothesis that negative self-schemas influence information-processing among depressed patients.
Depressed Patients Have Negative Self-Esteem
Beck proposes that depression is, in part, maintained by negative self-esteem and negative self-image. Self-esteem or sense of personal worth is considered to be a conscious cognitive evaluation of the self congruous with the self-schemas. The self is viewed as an organized memory structure containing representational self-referent material (Kuiper & Olinger, 1986). Several studies of self-esteem and depression have shown depressed patients to score
lower on measures of self-esteem (e.g., Feather, 1983) and higher on measures of self-consciousness (Sacco & Hokanson, 1978) than nondepressed people.
lower on measures of self-esteem (e.g., Feather, 1983) and higher on measures of self-consciousness (Sacco & Hokanson, 1978) than nondepressed people.
Table 2-1. Systematic errors of thinking in depression (adapted from Burns, 1999) | |
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