Cognitive Therapy for Chronic and Persistent Depression / Edition 1

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This book is essential reading for any therapist working with these hard to help patients, such as clinical psychologists, psychiatric nurses, psychiatrists, social workers and counsellors.
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Product Details

Meet the Author

Richard Moore works as a clinical psychologist in the Department of Cognitive and Behavioural Psychotherapies at Addenbrooke's Hospital in Cambridge. After obtaining an M.A. and a PhD. from the University of Cambridge and completing his clinical psychology training at the University of Edinburgh, he trained as a cognitive therapist at the Center for Cognitive Therapy in Philadelphia. He has been a therapist on major controlled trials of cognitive therapy for recurrent and residual depression in Edinburgh and in Cambridge. He is a Founding Fellow of the Academy of Cognitive Therapy.

Anne Garland  is a nurse consultant in psychological therapies at the  Nottingham Psychotherapy Unit. After training in cognitive therapy at Sheffield and Oxford, Anne worked as a therapist in two Medical Research Council funded trails investigating the efficacy of using cognitive therapy in the treatment of residual depression and bi-polar disorder. She has developed clinical expertise in the delivery of cognitive therapy across NHS service settings including primary care, community mental health teams, inpatient units and specialist psychotherapy services. She is currently President-elect  to the British Association of Behavioural and Cognitive Psychotherapies (BABCP) as a member of the psychotherapy accreditation sub-committee.

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Read an Excerpt

Cognitive Therapy for Chronic and Persistent Depression

By Richard G. Moore Anne Garland

John Wiley & Sons

Copyright © 2003

Richard Moore, Anne Garland
All right reserved.

ISBN: 0-471-89278-5

Chapter One


In this chapter, you will find information on:

The standard cognitive model of acute depression

Problems encountered in applying this model in persistent depression

Three kinds of avoidance that obscure the relationship between negative
automatic thoughts and negative emotions

The nature of overt negative thinking and important underlying
beliefs in persistent depression

Social factors that can trigger or maintain persistent depression

Early experiences that can contribute to the formation of maladaptive
belief systems

How beliefs, overt negative thoughts, avoidance processes and social
adversity combine to manifest in low self-esteem, helplessness and

The implications of the model for the overall conduct of cognitive

Cognitive therapy for depression is based on the theoretical and clinical
model described by Beck, Rush, Shaw and Emery in their influential book
Cognitive Therapy of Depression (1979). This model describes the negative
thinking characteristic of depression and how this relates to the symptoms
and to otheremotional, behavioural and situational aspects of the
illness. Factors contributing to the manifestation of negative thinking are
also considered. These factors include early experiences that influence the
development of beliefs and attitudes, and subsequent situations or events
that trigger the disorder in vulnerable individuals. The model is used as a
guide for the therapist in formulating how depression is maintained in a
particular case.

The application of the standard cognitive model in cases of persistent
depression can result in confusion and frustration for both patient and
therapist. In this chapter, we discuss how the cognitive model for acute depression
needs to be adapted in order to apply it to persistent depression. In
outline, we propose that the crucial cognitive characteristics in persistent
depression are low self-esteem, helplessness and hopelessness. Vulnerability
to these thinking patterns arises from the enduring and rigid nature
of patients' negative beliefs about themselves and their social world. The
persistent threat of distress results in the adoption of maladaptive coping
styles, which exacerbate the problems that patients face. Once depressed,
patients' experiences, shaped by their beliefs and coping style, confirm
and entrench low self-esteem, helplessness and hopelessness. As we have
described in the introduction, persistent depression is not a homogeneous
problem. Patients' histories, course of current episode and presentation
can vary widely. The model describes factors that potentially contribute to
the maintenance of depression and help to account for some of the variation
in presentations of persistent depression. These factors then need to
be considered in constructing a cognitive formulation and treatment plan
for each individual case.


Automatic Thoughts

The standard cognitive model of Beck and colleagues (1979) describes negative
thinking in depression at three levels: negative automatic thoughts,
thinking errors or biases and underlying beliefs or assumptions. Firstly,
many of the spontaneous or automatic thoughts of people with depression
are manifestly negative. Such negativity focuses on the self, the world and
the future: the negative cognitive triad. People suffering from acute depression
tend to see themselves as defective or inadequate, and see the world as
presenting them only with insuperable obstacles and difficulties. They see
such problems persisting indefinitely into the future and are pessimistic to
the point of hopelessness and perhaps suicidal wishes. When these negative
automatic thoughts come to mind, they trigger feelings of misery and
despair or exacerbate an existing low mood state. Negative emotions or
low mood can prime these negative thoughts, making them more likely
to come to mind and more believable when they do. As low mood primes
the negative thoughts, which then further exacerbate low mood, a vicious
circle is set up whereby the person's mood can spiral downwards. This
can also lead to procrastination and inactivity, which further feed into the
vicious circle, as illustrated in Figure 1.1.

Cognitive Biases

The negative content of thinking manifest in these negative automatic
thoughts results in part from certain biases or distortions in the processing
of information. These biases include all-or-nothing or 'black and white'
thinking, personalisation and jumping to conclusions. Dichotomous or
'black and white' thinking is central, whereby the person sets unrealistically
high standards for their own performance. If these standards are
not met, negative judgements ensue. For example, this processing bias
could readily be identified with one patient, Elizabeth, from the early stages
of therapy and was a target for intervention. If something did not meet
Elizabeth's exacting high standards it was dismissed as substandard and
of no value. Elizabeth saw no shades of grey, so that even an adequate
outcome was seen as not making the grade. Black and white thinking can
lead to a mental filter, such that positive or neutral aspects of a situation are
ignored, whereas negative aspects are selectively focused on and dwelt on
at length. Having such high standards served to focus Elizabeth continually
on her shortcomings. Her expectation of failing to meet her standards
accounted in large part for the avoidance and procrastination that had pervaded
her life since the onset of her depression. Elizabeth's thinking biases
are evident in the following discussion that took place while reviewing one
of her homework assignments.

T: How did you get on with keeping your diary of automatic thoughts?

E: Not very well.

T: Have you got it with you?

E: Yes. It's a mess.

T: Could we take a look at it together?

E: Okay (shows completed diary to therapist).

T: Right. Mmm ... You've written down three examples. What makes you
say you have not done it very well?

E: My handwriting is very untidy.

T: I can read it though, isn't that the most important thing?

E: It looks awful.

T: Anything else you are unhappy with?

E: I don't think I've done it properly.

T: Mmmm.... We've spoken about your sense of not doing things properly
before. How are you defining properly in this instance?

E: I haven't written down all the thoughts I intended to. I'm bound to
have missed some important thoughts, I'm so forgetful these days.
Also, I didn't always write them down immediately as you suggested.
I waited half an hour or so.

T: Okay let's summarise. You have very ably identified what you see as
your shortcomings in completing the diary. You see your handwriting
as untidy and as far as you are concerned it has not been done properly.
Can I ask-even if it has not met your exacting standard, is it of no use
to us today in our session?

E: Mmmm ... I see what you're saying.

T: So if this is the black and white position are there any shades of grey

E: (sighs) I suppose. I guess I did write down three thoughts and like you
said you can read it, which is the point really.

In addition, depressed people frequently personalise any negative outcomes,
by assuming the blame for things that go wrong or seeing personal
rejection in any uncomfortable social situation. Thoughts that exemplify
this kind of bias include 'It's all my fault' or 'I should have stopped this
happening'. Personalisation pervaded Jean's thinking in most interactions
with other people. For example, if she argued with her partner she invariably
concluded it was her fault. This was sometimes taken to the extreme
that if someone refused a request, Jean took this as evidence that she had
offended them in some way or that they were exacting revenge for some
past misdemeanour on her part.

Negative biases may also be in the form of arbitrary inferences, where the
depressed person jumps to the most negative conclusion about a situation
in the absence of any evidence. Patients often predict quite catastrophic
outcomes for future events, while perfectly plausible benign or beneficial
outcomes are never conceived or are dismissed as highly unlikely. This
way of thinking is particularly characteristic of depressed patients who
present with significant anxiety symptoms. Marion tended to predict that
any event from making a request of her daughter to attending a social gathering
or therapy session was likely to end in absolute disaster. In the early
stages of treatment, Marion asked to end the therapy. After some discussion,
it transpired that before each treatment session Marion's mind was
bombarded by negative thoughts regarding the fact she had not completed
her homework. This typically began with thoughts such as 'I'm too tired'
and 'It won't help' and then turned to predicting that the therapist would
think that she was lazy. This thinking quickly got out of proportion to such
an extent that she would picture the therapist shouting at her and telling
her she was a waste of space. She imagined the therapist writing to her
psychiatrist to tell him the same, resulting in the psychiatrist washing his
hands of her. Her request to be discharged helped her to exert some control
over what she perceived with absolute certainty would be the inevitable
outcome of the non-completion of homework assignments. Marion had no
evidence to support these predictions, but when depressed and anxious
her thinking was dominated by this kind of negative processing.

Dysfunctional Assumptions

The third level of negative thinking is that of longstanding cognitive
structures that predate the onset of the episode of depression and whose
activation results in cognitive biases and automatic thoughts. In cases of
acute depression, conditional beliefs or assumptions are thought to confer
the cognitive aspect of vulnerability. These conditional beliefs typically set
out the conditions that must be satisfied for the person to adopt a sense
of worth, fulfilment or happiness. Elizabeth's rule 'If you can't do something
properly then there is no point in doing it at all' was manifest in
the above example. If rigidly applied, such a belief increases the likelihood
of depression when those high standards are not met, whether this is
due to internal or external factors. The limitations imposed by the symptoms
of depression prevented Elizabeth living up to her standards and so
caused her much distress. Other common conditional beliefs in depression
are 'If anyone criticises or rejects me, it shows I am an unlikeable person'
and 'I cannot be happy unless I am loved by others'. These conditional
beliefs are similar to quite functional beliefs held by many people, in that
most people would prefer to be loved and not to be criticised or rejected.
However, they are unhelpful in their extremity or the rigidity with which
they are applied to situations where the conditions are perceived as not
being met.

In the cognitive model of depression, these conditional beliefs are thought
to develop in many cases through early life experiences. Where parents
have been excessively critical, the child may internalise the implicit rule
that being valued only comes from perfect performance, as was the case
for Elizabeth. This assumption may become latent or silent during parts
of adult life where any endeavours are met with a reasonable degree of
success. Thus, prior to becoming depressed, Elizabeth had, by unrelenting
hard work, managed to live up to the excesses of her conditional belief.
However, any notable failures activate the latent assumption and the person
becomes sensitised to any signs of falling short of their perfectionistic
standard. The onset of Elizabeth's depression was triggered by public criticism
from her coworkers for dutifully following company procedures that
were commonly flouted. The demand she placed on herself always to do
things 'properly' (in this instance, stick to the rulebook) led to her being
criticised. This criticism was perceived by her as a failure to live up to
others' expectations of her. However, had Elizabeth decided to flout the
rules along with everyone else, she would in her eyes have failed in the
expectations she set for herself. This illustrates the impact of stringent adherence
to inflexible rules, which in this instance put Elizabeth in a no-win


In using this model of depression with acute cases, pertinent negative
thoughts are often self-evident. Once the patient is socialised to the cognitive
model, automatic thoughts can readily be identified and are often
amenable to cognitive interventions. It would seem reasonable to expect
that persistent depression would be characterised by a thinking style in
which these negative automatic thoughts, processing biases and structures
would be chronically manifest. Indeed this is often the case, and the therapist
is assailed by a barrage of self-criticism and overwhelming negativity
from the patient. A chronic cognitive triad (see pages 55-59) of low self-esteem,
helplessness and hopelessness is often manifest in overt negative
thoughts about the self, the world and the future. The extremity and rigidity
of this negative thinking can be difficult to contain and manage, as was
the case with Elizabeth. However, this barrage of negativity is not the only
notable thing in the experience of therapists working with resistant depression.
A number of common features of presentation in these patients can
make it hard to see immediately how the cognitive model applies. These
include a reluctance of some patients to discuss their problems or thoughts;
globality of thinking that is hard to relate to particular problems; and an
apparent lack of relationship between the patients' negative thoughts and
low moods.

Firstly, with some chronically depressed patients, it can be hard to gain
from them any idea of what their problems are or even that they have any
problems. In the early stages of contact, some patients are reluctant to talk
about any problems they are having. Although some reluctant patients will
assent to direct questions about their problems, others may explicitly refuse
to discuss certain issues. Even where an initial assessment has seemed fairly
innocuous to the therapist, the patient may express reluctance to continue
with the therapy during or after the initial contact.

The therapist's difficulty applying the cognitive model does not always
stem from this reluctance of patients to discuss their problems. Plenty of
patients with persistent depression have many problems that they wish
to discuss and on occasion the therapist can be faced with an apparent
tidal wave of different problems affecting every area of a patient's


Excerpted from Cognitive Therapy for Chronic and Persistent Depression
by Richard G. Moore Anne Garland
Copyright © 2003 by Richard Moore, Anne Garland.
Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

About the Authors
Introduction: The Challenge of Persistent Depression 1
Ch. 1 The Cognitive Model of Persistent Depression 21
Ch. 2 The Foundations of Therapy: Therapeutic Relationship, Style and Structure 69
Ch. 3 Initial Assessment and Formulation 94
Ch. 4 Initiating Therapy: Socialisation and Setting Goals 137
Ch. 5 Using Standard Behavioural Techniques 171
Ch. 6 Working with Automatic Thoughts 198
Ch. 7 Recognising Underlying Beliefs and Their Effects 231
Ch. 8 Modifying Underlying Beliefs 257
Ch. 9 Working with Some Typical Themes in Persistent Depression 291
Ch. 10 Beyond Therapy: Preventing Relapse and Furthering Progress 319
Ch. 11 Delivering Treatment 341
Ch. 12 Outcomes and Processes of Therapy 354
App. 1 Meet the Patients 372
App. 2 Handouts for Patients 381
References 397
Index 407
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