The Cognitive Theory Of Depression

CT rests on a theoretical model of human functioning that has been elaborated over the years. This model is based on a Realist epistemology (Dobson & Dozois, 2001; Held, 1995), which asserts that reality exists independent of human experience. At the same time, the model holds that humans are "natural scientists" and seek to make sense of the world and their experiences, through the development of broad, organizational cognitive constructs. The constructs were typically defined as "core beliefs" or "underlying assumptions" in early descriptions of CT, but over the years the term "schema" (Kovacs & Beck, 1978) has come to predominate in the literature. Regardless of the specific term, the general concept imparted is that all individuals, through a combination of forces (personal experience, parenting, peer relations, media messages, popular culture), develop global, enduring representations of themselves, people in their world, and the way that the world functions. These cognitive representations may be accurate or distorted, but for individuals who eventually become depressed, they are characteristically negative. The relationship between negative thinking and depression has been generally supported in research (cf. Clark, Beck, & Alford, 1999), even though there continues to be a discussion about whether or not depressed persons are more "realistic" than nondepressed persons, and that the nondepressed part of the population perhaps distorts perceptions in an unduly positive direction (Ackermann & DeRubeis, 1991; Dobson & Franche, 1989). Negative representations often establish expectations for the self, or the self in relation to others in the world, that increase the risk of depressive ways of thinking and behaving.

The cognitive model is often discussed as a diathesis-stress model (Monroe & Simons, 1991; Robins & Block, 1989), reflecting the idea that negative core beliefs, assumptions, or schemas represent diatheses, or vulnerabilities, that then interact with life stress to eventuate in a process leading to depression (see Figure 1.1). There is consistent evidence that depression often is predicted by significant negative life events (Monroe & Simons,

FIGURE 1.1. The cognitive model of depression.

1991). Some of these events are independent of the person's control, such as some interpersonal losses, but others may actually be inadvertently established or maintained by the depressed person him/herself (Davila, Hammen, Burge, Paley, & Daley, 1997; Joiner & Schmidt, 1998). For example, an individual who has developed a core belief of him/herself as a "loser," and as someone who cannot form an intimate relationship, may well avoid social situations or rebuff interpersonal advances. The resulting social isolation then becomes a life event that perpetuates the very negative belief of being an interpersonal "loser" that led to these behaviors in the first instance.

Regardless of whether the life events that interact with or trigger negative beliefs and assumptions are truly exogenous to the person, or whether in some unwitting way these events are the result of the depressed person's own actions, the cognitive model states that once the diathesis and stress have interacted, characteristically negative thinking emerges. This negative thinking may accurately reflect negative life events, but it is quite common in depression for this thinking to become negatively skewed, and possibly even to be at some variance with the actual events in the world. "Cognitive distortions," as they are called (Beck et al., 1979; J. S. Beck, 1995), can take a number of specific forms, including magnification of problems, minimization of success, jumping to conclusions, mind reading, black-and-white or absolutistic thinking, and labeling, among others. These distortion processes in turn lead to negative thinking in specific situations, or what may be termed "automatic thoughts." The term "automatic" refers to this thinking, because it is typified by reflexive and unquestioned appraisals based on the core beliefs that prompted them. Also, because negative thinking is congruent with depressed mood, these thought patterns are often seen as "reasonable" by the depressed person.

The cognitive model of depression further asserts that the negative automatic thoughts, or interpretations of situations, lead to specific feelings and behaviors. For example, the thought that one cannot take any positive action to solve problems leads to feelings of helplessness and a lack of action. The perception that one's problems will never improve can lead to feelings of hopelessness and escapist behaviors, including suicide. Finally, the model asserts that once a person starts to feel depressed, there is a feedback process, such that negative affect increases the probability of further negative thinking, and also reinforces negative beliefs and schemas. Feedback also occurs because depressive behaviors, such as avoidance and withdrawal, tend to increase the prospect of negative events through processes such as social isolation or social rejection (Coyne, 1976; Joiner, 2000).

The cognitive model of depression helps to explain why the typical complaints of depressed patients relate to their emotional experience and inability to cope with life's demands, because the emotional and behavioral aspects of depression are in some respects the "end" of the process of depression. The role of the cognitive therapist is to translate the problems of the patient who comes to treatment into a case formulation that explains the core beliefs or schemas that have interacted with life events to eventuate in the process leading to depression (Persons, 1989; Persons & Davidson, 2001; see also Whisman & Weinstock, Chapter 2, this volume). This case formulation then becomes the basis for deciding on strategic targets of change, with the goal of solving problems and reducing depression. Choosing which problems to address first in therapy is a matter of clinical experience and skill, but the case conceptualization guides this process.

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