“Mr. Rodrigo enters my psychology practice. He tells me that he hasn’t felt like living for a long time: he has been sad for a long time, he doesn’t feel like doing anything and he doesn’t see anything that could make him feel any better. Even things that he used to be passionate about are now just a hindrance. In addition to this, it indicates that he does not see that the situation will improve at any time, having considered being a hindrance to his loved ones. They were good to him at first, but in time they got tired, and now he is alone. As far as he is concerned, together with the results obtained from the various tests and evaluation measures that I apply to him, everything suggests that we are dealing with a case of major depressive disorder. However, the time has come to ask myself, what can I do as a professional to help him improve his situation?

Analyzing the case: depression

Depression. This word is commonly used, in everyday language, to refer to a state of sadness that remains for a time interval. However, this use of the concept in everyday language loses much of what the term implies on a clinical level.

In clinical terms, the presence of a major depressive disorder is considered to be the presence for at least two weeks followed by depressive episodes, which are defined by the presence of five symptoms, one of which is a sad mood and/or the presence of apathy (lack of motivation/interest) or anhedonia (absence of pleasure). Other symptoms include changes in appetite/weight, fatigue, agitation or slowing down, guilt and thoughts of suicide. To be considered as such it has to interfere with daily life and not be due to other disorders, such as psychotic ones. It is one of the most common mood disorders in the population.

While these are the typical symptoms of depression, the question remains: how to interpret and treat it?

Treating Depression

There are numerous models that attempt to explain the depressive process and its causes. This wide diversity means that there are fortunately a great many techniques for treating depression. One of the known, successful and currently used ones comes from Beck’s Cognitive Theory.

Beck’s cognitive model

This theory considers that the elements that are most important in depression are the cognitive ones . According to this theory, the main problem of depressed subjects is the cognitive distortion when interpreting the phenomena of reality, focusing the attention on schemes of knowledge according to our cognitions. Due to these schemes and distortions, we have negative thoughts regarding our own self, the future that awaits us and the world around us (thoughts known as cognitive triad).

Based on this theory, Beck himself designed cognitive therapy to treat depression (although it has subsequently been adapted to other disorders).

Beck’s Cognitive Therapy for Depression

This therapy has been developed so that patients can discover more positive ways of interpreting reality , moving away from the depressive patterns and cognitive distortions characteristic of depression.

The aim is to act from a collaborative empiricism in which the patient actively participates by creating situations that allow him/her to make behavioural experiments (that is, to test his/her beliefs), which will be proposed between the therapist and the patient himself/herself. Likewise, the psychologist will not confront the dysfunctional beliefs directly, but will favour a space of reflection for the patient, so that ultimately it is he who sees the inaccuracy of his beliefs (this way of proceeding is known as the Socratic method).

In order to act in this field, we will work on cognitive, behavioural and emotional techniques.

Behavioral techniques

This type of technique aims to alleviate the lack of motivation and eliminate the passivity of depressed patients. In the same way, they also allow to test one’s own beliefs of guilt and uselessness, being its basic operation the realization of behavioral experiments.

1. Assignment of graduated tasks

It is based on negotiating the completion of various tasks, graduated according to their difficulty , so that the patient can test his beliefs and increase his self-concept. The tasks must be simple and divisible, with a high probability of success. Before and after performing them, the patient must record his/her expectations and results, in order to contrast them later.

2. Programming of activities

The activities that the patient will do, including schedule, are programmed . The aim is to force the elimination of passivity and apathy.

3. Use of pleasurable activities

Designed to eliminate anhedonia, it is about making people do activities that are or will be rewarding , proposing them as an experiment and trying to monitor the effect of self-fulfilling prophecy (that is, that there is no failure because the belief that one will fail induces it). To be considered a success, it is enough that there be a decrease in the level of sadness.

4. Cognitive testing

This technique has great relevance. In it the patient is asked to imagine an action and all the steps required to complete it , indicating possible difficulties and negative thoughts that could interrupt it. Likewise, it seeks to generate and anticipate solutions to these possible difficulties.

Cognitive techniques

This type of techniques are used in the field of depression with the aim of detecting dysfunctional cognitions and replacing them with more adaptive ones . Some of the most commonly used cognitive techniques are the following:

1. Three-column technique

This technique is based on a self-registration by the patient , indicating in a daily record the negative thought he has had, the distortion committed and at least an alternative interpretation to his thought. Over time, more complex tables can be made.

2. Downshift technique

On this occasion , the aim is to go deeper and deeper into the patient’s beliefs , bringing to light the deeper beliefs that provoke negative thoughts. That is to say, one begins with an initial affirmation/thought, to later see what makes one believe such a thing, then why one thinks this second idea, and so on, looking for an increasingly personal and profound meaning.

3. Reality tests

The patient is asked to imagine his/her perspective of reality as a hypothesis to be contrasted , to later design and plan activities that can contrast it. After carrying out the behavioural experiment, the results are evaluated and the initial belief is worked on in order to modify it.

4. Record of expectations

A fundamental element in many of the behavioural techniques , it aims to contrast the differences between initial expectations and real results of behavioural experiments.

Emotional techniques

These techniques seek to reduce the negative emotional state of the patient through management strategies , dramatization or distraction.

An example of this type of technique is time projection. This technique aims to project into the future and imagine an intense emotional situation, as well as how to face and overcome it.

Structuring of therapy

Cognitive therapy against depression was proposed as a treatment to be applied between 15 and 20 sessions , although it can be shortened or lengthened depending on the needs of the patient and his or her evolution. A sequencing of the therapy should firstly go through a previous assessment, to later move on to the implementation of cognitive and behavioural interventions and finally contribute to modifying the dysfunctional schemes. A possible sequencing by phases could resemble the following one:

Phase 1: Contact

This session is mainly dedicated to the collection of information about the patient and his or her situation. Likewise, the aim is to generate a good therapeutic relationship that allows the patient to express himself/herself freely.

Phase 2: Start of intervention

The procedures to be used throughout the treatment are explained and the problems are organized so that the most urgent is worked on first (the therapy is structured differently, for example, if there is a risk of suicide). Expectations regarding therapy are worked on. The psychologist will try to visualize the presence of distortions in the discourse, as well as elements that contribute to maintaining or resolving the depression. Self-registration is developed.

Phase 3: Implementation of techniques

The carrying out of the activities and behavioural techniques described above is proposed . The cognitive distortions are worked on with the cognitive techniques, considering the need to carry out behavioural experiments.

Phase 4: Cognitive and behavioral work

Cognitive distortions are worked on based on the experience obtained from behavioral experiments and the comparison of self-registrations with respect to real performance.

Phase 5: Reassignment of responsibility

Each time, the responsibility for establishing their agenda begins to be delegated to the patient , increasing their level of responsibility and autonomy, with the therapist acting as supervisor.

Phase 6: Preparation for completion of therapy

The continuation of the strategies used in therapy is encouraged and strengthened . Little by little the patient is prepared to identify possible problems and prevent relapses. The patient is also prepared for the end of the therapy. The therapy is completed.

Bibliographic references:

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Fifth edition. DSM-V. Masson, Barcelona.
  • Beck, A.T. (1976). Cognitive therapy and the emotional disorders. International University Press, New York.
  • Belloch, A.; Sandín, and Ramos (2008). Manual of psychopathology. Madrid. McGraw-Hill (vol. 1 and 2). Revised edition.

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  • Santos, J.L. ; García, L.I. ; Calderón, M.A. ; Sanz, L.J.; de los Ríos, P.; Izquierdo, S.; Román, P.; Hernangómez, L.; Navas, E.; Ladrón, A and Álvarez-Cienfuegos, L. (2012). Clinical Psychology. Manual CEDE de Preparación PIR, 02. CEDE. Madrid.