The psychologist in cases of depression: cognitive-behavioral treatment

How do psychologists act when faced with a case of depression?

"Mr. Rodrigo comes into my psychology office. He tells me that he has not felt like living for a long time: he has been sad for a long time, he does not feel like doing anything and he does not see anything that could make him feel the slightest illusion. Even things he used to be passionate about are now just a mere hindrance. In addition to this, he indicates that he does not see that the situation is going to improve at any time, having considered being a nuisance for his loved ones.

At the beginning they behaved well with him, but with time they got tired of him, and now he is alone. From what he refers, together with the results obtained from the various tests and evaluation measures applied to him, everything suggests that we are dealing with a case of major depressive disorder. However, it is time 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 lasts for a temporary interval. However, this use of the concept in everyday language loses much of what the term implies at the clinical level.

In clinical practice, the presence of a major depressive disorder is considered to be the presence for at least two weeks in a row of depressive episodes, which defined by the presence of five symptoms, one of them being sad mood and/or the presence of apathy (lack of motivation/interest). (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 must interfere with daily life and not be due to other disorders, such as psychotic disorders. It is one of the most common mood disorders in the population.

While these are the typical symptoms of depression, the question arises: 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 fortunately there are a large number of techniques available to treat depression. One of the best known, successful and currently used comes from Beck's Cognitive Theory.

Beck's Cognitive Model

This theory considers that the most important elements in depression are the cognitive ones.. According to this theory, the main problem of depressed subjects is cognitive distortion when interpreting the phenomena of reality, focusing attention on knowledge schemes consistent with our cognitions. Due to these schemes and distortions, we have negative thoughts about 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 to help patients discover more positive ways of interpreting reality, away from the patterns of depression and depression.away from the depressogenic schemas 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 to conduct behavioral experiments (i.e., to test his beliefs), which will be proposed between the therapist and the patient himself. Likewise, the psychologist will not confront the dysfunctional beliefs directly, but will favor a space for reflection for the patient, so that ultimately it is the patient who will see the inaccuracy of his beliefs (this way of proceeding is known as the Socratic method).

In order to act in this area, we will work on the basis of cognitive techniques as well as behavioral 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 testing one's own beliefs of guilt and uselessness, being its basic operation the realization of behavioral experiments.

1. Assignment of graded tasks

It is based on negotiating the performance of various tasks, graded according to their difficulty, so that the patient can put to the test his or her own guilt and uselessness beliefs.The tasks should be simple and simple, and the patient should be able to test his or her beliefs and increase his or her self-concept. The tasks must be simple and divisible, with a high probability of success. Before and after performing them, the patient should record his expectations and results, in order to contrast them afterwards.

2. Programming of activities

The activities to be carried out by the patient are programmed, including timetable. The aim is to force the elimination of passivity and apathy.

3. Use of pleasurable activities

Designed to eliminate anhedonia, it is a question of making to carry out activities that result or will result gratificantesThe aim is to propose them as an experiment and to watch out for the self-fulfilling prophecy effect (i.e., that there is no failure because the belief that one will fail induces it). A decrease in the level of sadness is sufficient to be considered a success.

4. Cognitive testing

This technique is of great relevance. In it, the patient is asked to imagine an action. the patient is asked to imagine an action and all the steps needed to complete it, indicating possible difficulties and negative thoughts that could interrupt it.indicating possible difficulties and negative thoughts that could interrupt it. It also 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 objective of detect dysfunctional cognitions and replace them with more adaptive ones.. Some of the most commonly used cognitive techniques are the following:

Three-column technique 2.

This technique is based on the realization of a self-recording by the patient, indicating in a daily record the negative thought he has had, the distortion committed and at least one alternative interpretation of his thought.indicating in a daily record the negative thought he/she has had, the distortion committed and at least one alternative interpretation of his/her thought. With time, more complex charts can be made.

2. Downward Arrow Technique

On this occasion the aim is to go deeper and deeper into the patient's beliefs, bringing to light the patient's beliefs.This technique is used to bring to light the deeper and deeper beliefs that provoke the negative thoughts. That is to say, we start from an initial affirmation/thought, and then we start to see what makes the patient believe such a thing, then why he/she thinks this second idea, and so on, looking for a deeper and deeper personal meaning.

3. Reality testing

The patient is asked to imagine his or her perspective of reality as a hypothesis to be tested.and then design and plan activities to test it. After performing the behavioral experiment, the results are evaluated and the initial belief is worked on in order to modify it.

4. Recording of expectations

A fundamental element in many of the behavioral techniques**, its purpose is to contrast the differences between initial expectations and real results** of the behavioral experiments.

Emotional techniques

These techniques seek to reduce the patient's negative emotional state by means of management strategies, dramatization or distraction.dramatization or distraction.

An example of this type of technique is temporal projection. The aim of this technique is to project oneself into the future and imagine an intense emotional situation, as well as the way to cope with it and overcome it.

Structuring of the therapy

Cognitive therapy against depression was designed as a treatment to be applied between 15 and 20 sessions, although it can be shortened.although it can be shortened or lengthened depending on the patient's needs and evolution.

A sequencing of therapy should first go through a pre-assessment, then moving on to cognitive and behavioral interventions and finally helping to modify dysfunctional schemas. A possible sequencing by phases could resemble the following:

Phase 1: Contact

This session is mainly devoted to gathering information about the patient and his situation. and his situation. It also seeks to generate a good therapeutic relationship that allows the patient to express him/herself freely.

Phase 2: Start of intervention

The procedures to be used throughout the treatment are explained and the problems are organized in such a way as to work on them first. so that the most urgent problem is worked on first (the therapy is structured differently, for example, if there is a risk of suicide). Expectations regarding the 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-records are elaborated.

Phase 3: Implementation of techniques

The activities and behavioral techniques described above are proposed.. Cognitive distortions are worked with cognitive techniques, considering the need for behavioral experiments.

Phase 4: Cognitive and behavioral work

Cognitive distortions are worked on on the basis of the experience obtained from the behavioral experiments and the contrast of the self-registers with respect to the real performance.

Phase 5: Re-attribution of responsibility

Responsibility for setting the patient's agenda is increasingly delegated to the patient, increasing his level of responsibility and autonomy.The patient's level of responsibility and autonomy increases, 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.. The patient is gradually prepared to identify possible problems and prevent relapses on his or her own. The patient is also prepared for the end of therapy. The therapy is completed.

Bibliographical 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 de psicopatología. Madrid. McGraw-Hill (vol. 1 and 2). Revised edition.

• 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). Psicología Clínica. Manual CEDE de Preparación PIR, 02. CEDE. Madrid.