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Cognitive behavioral treatment (CBT) of depression is a psychotherapeutic treatment approach that involves the application of specific, empirically supported strategies focused on changing negative thinking patterns and altering behavior. In order to alleviate the symptoms of depression, treatment is directed at the following three domains: cognition, behavioral and physiological. In the cognitive domain, patients learn to apply cognitive restructuring techniques so that negatively distorted thoughts underlying depression can be corrected, leading to more logical and adaptive thinking.
Within the behavioral domain, techniques such as activity scheduling, social skills training and assertiveness training are used to remediate behavioral deficits that contribute to and maintain depression such as social withdrawal and loss of social reinforcement. Finally with in the physiological domain, patients with agitation and anxiety are taught to use imagery, mediation and relaxation procedures to calm their bodies (Beck, Rush, Shaw & Emery, 1979). Process Cognitive Behavioral Therapy combines the processes of cognitive therapy and behavioral therapy into one treatment.
Cognitive therapy teaches a client the connection between thought patterns, emotional state and behavior. Cognitive therapy encourages the client to change irrational and negative thinking patterns in order to alleviate the emotional symptoms that are caused by the thoughts. Behavioral therapy teaches the client how to change learned reactions that cause maladaptive behaviors. It is a common assumption that thoughts, and not external stimuli, directly cause emotions and behaviors and the cognitive part of CBT concentrates on the client’s thoughts.
CBT helps the client identify negative and irrational thoughts and replace them with more rational and more positive thoughts. Automatic thoughts are often the most powerful in affecting our emotions and behaviors as they are the cognitive reactions to feared situations. Automatic thoughts breed assumptions and effect core beliefs. CBT targets negative and irrational beliefs and thoughts in the client’s mind (Kozak, 2003). Cognitive therapy hypothesizes that certain individuals possess negative beliefs, or self-schemata’s.
Specifically, individuals have a negative view of themselves, their environment, and their future. This negative way of thinking guides one’s perception, interpretation and memory of personally relevant experiences, thereby resulting in a negatively biased construal of one’s personal world and ultimately to the development of maladaptive symptoms. Individuals are more likely to notice and remember situations in which a sense of failure or deficit in personal standards occur and then discount or ignore successful situations.
As a result, the negative sense of self is maintained and may lead to depression (Beck, 1979). Cognitive-behavioral therapy is an action-oriented form of psychosocial therapy that assumes maladaptive, or faulty, thinking patterns cause maladaptive behavior and negative emotions. Maladaptive behavior is behavior that is counter-productive or interferes with everyday living. The treatment focuses on changing an individual’s thoughts, or cognitive patterns in order to change his or her behavior and emotional state.
Theoretically, cognitive-behavioral therapy can be employed in any situation in which there is a pattern of unwanted behavior accompanied by distress and impairment. It is a recommended treatment option for a number of mental disorders (Ford-Martin, 2002). Cognitive therapists believe that maladaptive cognitions arise from faulty social learning, dysfunctional family experiences, or from traumatic events. Cognitive behavioral therapy has a tremendous effect on clients with psychological problems.
The effects of this treatment have been proven to be extremely powerful in treating many psychological problems by approaching irrational and or negative automatic thoughts and changing behavioral reactions to fearful and avoidance causing situations. Specific processes of CBT include analyzing one’s automatic thoughts and replacing them with more rational and positive alternative thoughts that are based more on fact and gradually exposing and accustoming the client to feared situations.
The positive effects of CBT come from attacking and defeating thoughts and behaviors that can cause negative emotions. CBT is powerful because it teaches the client about the detrimental significance of the maladaptive thinking processes and maladaptive behaviors have triggered thoughts based more on assumptions than facts. This, in turn, has a powerful influence on affecting the client’s behavior in a healthy and positive direction (Kozak, 2003). Process and Steps CBT is oriented towards empowering the patients.
Within this specific, brief psycho-therapeutic treatment modality, the emphasis is on providing patients with skills to offset maladaptive symptoms. The two primary goals of CBT is to first create a therapeutic alliance between client and therapist and then, to use that alliance to facilitate treatment techniques within therapy sessions to create a positive emotional spiral wherein patients can implement specific strategies to offset their maladaptive symptoms, thus called cognitive restructuring (Sanderson, 2000).
The first step in facilitating cognitive change is to develop and maintain a therapeutic alliance between client and therapist. The term “collaborative empiricism” characterize the nature of the therapist-patient relationship in cognitive therapy. The therapist is active and directive and facilitates a rational approach to thinking with regard to the patients current life circumstances, using the principles of logic and scientific method. In order to foster this spirit of collaborative empiricism, cognitive behavioral therapists typically begin treatment by educating patients about their disorder.
Helping patients understand the cognitive behavioral model of depression particularly important in strengthening the treatment rationale and subsequent patient compliance (Beck, et al, 1979). A second essential step of the therapeutic element to cognitive behavioral therapy is called cognitive restructuring. This is a method of identifying and replacing fear-promoting, irrational beliefs with more realistic & functional ones. Cognitive restructuring is used to offset negative thought patterns.
Cognitive therapy incorporates a range of behavioral techniques and specific strategies to change cognition and facilitate cognitive restructuring. Cognitive restructuring is a therapeutic strategy that focuses directly on negatively-biased information processing maintained by individuals exhibiting maladaptive thoughts, feelings and/or feelings (Lewinsohn, Munoz, Youngren & Zeiss, 1986). Cognitive restructuring includes a set of skills that involves verbal mediation and affirmation.
Individuals use self-talk, or verbal mediation that creates a forum for thoughts to become more salient and more manageable. Affirmation is a statement of positive self-belief regarding the self-talk thoughts. Cognitive restructuring does not refer to the reorganization of information in the brain. The constant reorganization of knowledge is referred to by such terms as assimilation, accommodation, and construction of knowledge. The term cognitive restructuring refers to the learner using cognitive or intellectual processes to restructure, or alter, the information that is being processed.
Cognitive restructuring makes it more likely that the information will be the focus of attention in the working memory, that it will be transferred effectively from working memory to long-term memory, and that it will be retrieved when it is needed for subsequent use (Smith, et al 1990). Adaptations Cognitive behavioral theory describes the role of faulty thinking that causes maladaptive thoughts, feelings and/or behaviors and suggests a way to recover from it through cognitive restructuring. The way individual’s process information is governed by structures called schemata.
These schemata are made up of rules for explaining incoming information and for retrieving what we have already learned. They are capable of exerting powerful effects on how individuals experience and relate to the world. Treatment consists of correcting faulty or illogical thinking by repeatedly confronting cognitive schemata with discrepant information from role-playing ; homework assignments. The entire procedure consists of three steps described below (Beck ; Emery, 1985). Step one consists of recognizing and identifying underlying irrational beliefs.
Before individuals can change their thoughts and thought patterns, they must first recognize what they are thinking. The actual thoughts or images in a person’s mind are called automatic thoughts. Thus the first essential step of cognitive restructuring is to teach people to begin identifying and monitoring their automatic thoughts. Automatic thoughts are repetitive, automatic self-statements that the individual says to themselves in certain situations, and can be positive or negative. Psychological problems develop when our automatic thoughts are consistently negative.
They are automatic because they are not the result of an analysis of the problem, but rather an immediate or automatic reaction to specific situations. When automatic thoughts control the emotional responses to people, problems, and events, evidence that contradicts the automatic thought is typically ignored. Since automatic thoughts create an expectancy of something negative and since many things in life are vague, and can be interpreted in many ways, people learn how to negatively evaluate the world so it is consistent with the negative automatic thoughts (Beck & Emery, 1985).
The best way to allow patients to see a connection between thoughts and reactionary emotions is to initiate self-monitoring of the thoughts occurring in the individual’s mind. The onset of emotion is an indication that an automatic thought has occurred. In addition to labeling thoughts, patients may also label the intensity of their negative affect and note the situation in which the thoughts occurred. It is during this stage that automatic thoughts must be identified and examined for any cognitive distortions that may be present. These cognitive distortions usually occur as unrealistic or irrational beliefs (Beck ; Emery, 1985).
Some irrational beliefs consist of: emotional reasoning (mood state dependent thinking based on the assumption that feeling something strongly necessarily makes it true), over generalization (use of a single negative event as evidence for a never-ending pattern of negative events), arbitrary inference involves drawing unwarranted connections between ideas that are either not logically (relating connections that aren’t necessarily connected), all-or-nothing thinking (statements with absolute terms such as always, never, completely, totally or perfectly), should statements (statements that suggest a desire to change some reality when the only real choice is between accepting or not accepting it), jumping to conclusions (when negative interpretations are made of events without evidence), fortune telling (unfounded predictions as if they are fact), mind-reading (prediction about other people’s thoughts or behaviors without evidence), selective negative focus (focusing on the negative aspects of situations and ignoring positives), disqualifying the positive (dismissing positive experiences), magnification and/or minimization (enlarging or shrinking shortcomings or accomplishments of self or others), catastrophizing (building up of consequences to an event so that they seem insufferable), personalization (interpreting an event/situation as having special meaning (usually negative), and labeling (extreme over-generalization). These irrational beliefs are all based on flawed or faulty logic and have the potential to be highly maladaptive for the person who holds them. One of the typical maladaptive consequences of these irrational beliefs is a negative mood state such as anxiety, depression or anger. Other maladaptive consequences are that these beliefs often interfere with the ability to solve problems and may lead to behaviors create additional difficulties (Beck, 1979). Step two consists of analyzing cognitions.
Once a patient has identified automatic thoughts and examined how the thoughts influence affect and behavior, the next step is for the therapist and patient to perform logical analysis by examining the evidence of the patients thoughts, determining if any cognitive distortions are present and attempting to generate alternative hypotheses. At this point cognitions are treated as hypotheses and subjected to logical analysis. Once a negative thought is identified, the therapist and patient can work together to determine if in fact previous evidence supports the prediction. In CBT, the focus is on understanding how the patient interprets life events and making the client understand that if distorted thoughts and images can be changed, then the accompanying negative emotional states and behaviors will change as well (Beck ; Emery, 1985). Step three consists of challenging the irrational beliefs.
Once the irrational belief underlying an automatic thought has been identified, it is important to refute these beliefs by examining the evidence for them and by looking for alternative explanations. Generic questions can be used to refute irrational beliefs in two ways: first questioning how certain particular outcomes are and to also question the worst outcome that could happen (Beck ; Emery, 1985). Step four consists of introducing and replacing rational cognitions. Once the information is examined, the individual can replace the negative thought with a more accurate and rational thought. This strategy is intended to move patients away from the exclusive cause of negatively biased information processing. The goal is to generate as many plausible alternative explanations as possible.
This increases the patient’s awareness of other possibilities and gives them a sense of the full picture and demonstrates the subjectivity involved in interpreting events that focus on the negative aspects of situations. Once evidence has been reviewed, distortions examined, and alternatives explored, the next step is to generate a rational response. Thus the goal would be to have the individual modify the original irrational thought to something more rational. Often the replacements for automatic thoughts become evident in the course of refuting the irrational beliefs on which they are based (Beck & Emery, 1985). According to theorists there are a number of different techniques that may be employed in cognitive-behavioral therapy to help patients uncover and examine their thoughts and change their behaviors.
They include: homework, cognitive rehearsal, guided discovery, journaling, modeling, systematic desensitization, validity testing, exposure therapy, diversion techniques, activity scheduling, graded task assignment, downward arrow technique, thought recording and more (Beck 1995, 1979; Corsini &, Wedding, 2000; Ford-Martin, 2002) CBT for Christian Abusers Spiritual considerations: To start an integrative approach to treating Christian men who abuse, focus should begin with the premise that God’s ultimate plan for his children is to experience His divine love, acceptance, forgiveness and protection, thus allowing individuals to receive God’s grace. Essential to emotional, physical and spiritual healing is the assurance of an all-loving and completely dependable God. Christians believe it is a humble and obedient life that allows them to receive the love and grace from God and promote true healing.
Therefore, the client must examine their healing needs and re-evaluate priorities by casting out all fears, forgiving self and others, overcoming doubt, shame and disbelief, rid worry, anger, bitterness and transcend from anger, resentment and hatred. This will allow the client to learn handing over one’s self to God in full surrender and perfect trust is an exchange of weakness for strength, disability for ability and the impartation of the resurrected life of Jesus (Van Leeuwen, 1990). In the pursuit of genuine inner healing, Christians need to become convinced of God’s own personal love for them. The journey towards healing becomes a quest to uncover their individual and personal relationship with the Lord.
It is difficult for individuals to embrace the belief that God fully accepts and loves them for who they are when they cannot apply the same beliefs about themselves and towards others. As long as the self remains an independent entity, the separatism will cause a deep sense of worry, anxiety, negativity, inferiority and self-doubt for the individual. The abuser already has a sense of true unworthiness at the core and believes they are not good enough to deserve or receive God’s mercy or grace. Integrative therapy could focus on having the patient recognize their own worth, abilities and deservedness of God’s love and grace so then can begin to see the worth and deservedness of others (Prochaska, 1982).
Within the framework of effective and consistent integrative therapy, the wounded client can eventually become convinced that God loves them and wants to heal them. The client must realize that divine healing is given so that we can fulfill God’s purpose. Abusers must recognize they are worthy and deserving of unconditional love and from the Lord, independent from their experiences with others. The bible teaches to love yourself, love one another and never fear because God will always be there to love and comfort you. Once an individual is filled with God’s grace and healed, we must then in turn help others receive God’s love and grace so that they may also find healing and salvation. The client can unite with the Lord, thus leading them to divine healing.
When we allow grace and love from God to truly penetrate our core, it is then that all fears, defenses and protective behaviors can begin to dissolve. God’s love allows our hearts to be pure and His grace allows us to be eternally protected, loved and healed (Prochaska, 1982). Underlying issue considerations Abuse, both verbal and physical, is on the rise in our society, and the Christian community is not exempt. Abuse in the marital relationship is often undetected or misdiagnosed. Effecting change is essential, as abuse will ultimately destroy any relationship, including a marriage. When Christians exhibit abusive behaviors and/or anger management issues, some individuals may seek both a psychological and theological mode of treatment.
In cases of physical abuse, the most damaging element is not the violence that is done to the body but the violence that is done to the human spirit, a violence that is dehumanizing and leaves its victims feeling confused, vulnerable, trapped, and worthless. One must look deeper to identify and understand the motivational factors beneath the behaviors that create the oppressive, controlling climate that evokes abusive behavior (Kroeger & Beck, 1998). The key motivational factor that defines an abusive male is a deep-seated need to be in control. Because of the abuser’s insecurities, feelings of inadequacy, and distorted beliefs about women and marriage, he feels he must control his wife or lose her.
The abuser will use manipulative and heavy-handed tactics to keep his wife off balance. Some tactics may include: intimidation, eliciting fear, guilt, pity, or anger, making a person feel vulnerable, in danger, unprotected, or helpless, put-downs, criticism, or verbal abuse causing shame or humiliation, controlling another’s schedule, keeping another ignorant regarding herself, the world, finances, or others, keeping a person in crisis, and thus occupied and off balance, conspiracy and turning others away from aiding the person creating situations in which there is no way to win, lying or gossip threatening self-harm or suicide, possessiveness and jealousy.
Although the behaviors in and of themselves are forms of abuse, it is the constant climate of destruction put upon another that leaves the identified victim feeling trapped, lacking confidence or hope (Kroeger & Beck, 1998). Approach modifications: To begin an integrative approach to treatment for depressive personalities, we must assist the patient with recognizing that transformation occurs, not by conforming to society and the world, but rather, allowing the Holy Spirit to transform our lives into the likeness of Christ. God’s ultimate plan for his children is to experience His divine love, acceptance, forgiveness and protection, thus allowing us to receive God’s grace. Essential to emotional, physical and spiritual healing is the assurance of an all-loving and completely dependable God.
Christians believe it is a humble and obedient life that allows us to receive the love and grace from God and promote true healing. Therefore, the depressed client must examine their healing needs and re-evaluate priorities by casting out all fears, forgiving others, forgiving self, overcoming doubt and disbelief, rid worry, anger, bitterness, hatred and resentment. This will allow the client to learn handing over one’s self to God in full surrender and perfect trust is an exchange of weakness for strength, disability for ability and the impartation of the resurrected life of Jesus. In the pursuit of genuine inner healing, depressives must pursue specific goals in order to smoothly and gradually promote emotional and behavioral change (Crabb, 1977).
Angry individuals maintain clear themes within their character, which are directly related to their unhealthy and maladaptive thoughts, feelings and behaviors. These themes are in direct relation with automatic thoughts, underlying assumptions, behaviors, defenses and schemas, all of which contribute directly to maladaptive and abusive interaction with others. The abusive individual experiences fear, abandonment, internalizing rejection, guilt, self-hatred, has a sense of feeling unworthy and hopeless, all which connect with the fears and the over all feeling of unworthiness that keeps these cognitive distortions, defenses, and schemas alive (Prochaska, 1982).
In treatment, specifically with a Christian or faith-based approach, the integration of a biblical perspective can be used as a holistic way in order to combat the depressive’s distorted thoughts, defenses and schemas to reveal and combat the core issues. In order to facilitate change, the depressed patients are encouraged to consider their thoughts and beliefs as hypotheses, challenge possible alternatives and search for resolutions, all the while using Christian perspective as the foundation and framework for the process. If this journey is successful, it should result in adaptive and healthy thoughts and behaviors, as well as an enhanced spiritual self (Crabb, 1977). Individuals may exhibit multiple symptoms that require both clinical treatment and spiritual connection.
Although there are multiple techniques, strategies and treatment modalities in which to assist an angry and abusive individual find healing, there are two directions that a therapeutic journey may take. These directions include setting therapeutic goals and incorporating them within the stages of the change process. During the treatment process, several goals may be implemented in attempts to change unhealthy thoughts and behaviors, while simultaneously incorporating Christian values and beliefs. Cognitively, the client learns to apply cognitive restructuring techniques learned in therapy so that the automatic, distorted thoughts and underlying anger can be corrected, leading to more rational and adaptive thoughts and behaviors.
Behaviorally, techniques are learned in therapy and then applied in order to alleviate behavioral deficits that contribute to and maintain anger that results in abusiveness. Physiologically, relaxation and stress management techniques may be used to reduce and control anger. Spiritually, Christian values and beliefs are incorporated into the therapeutic process in order for the patient to establish or enhance the patient’s faith and ultimately their connection with God, Christ and the Holy Spirit. The primary goal is to surrender over to the God as the individual realizes that only God has control (Hurding, 1985). Behavior may be built on a false premise or faulty thinking. The tructure may seem rational to the patient because their belief system was built on an irrational and unrealistic foundation. People sometimes believe lies they were told as a child or that came out of a traumatic experience and some will even believe they are no longer useful to God because of what has happened to them. Erroneous thinking must be changed to biblical thinking and help the counselee identify the lie and replace it with truth. During this process, the counselor acts as the facilitator to help lead or recover a relationship between the client and the Lord. Through variety of techniques, the therapeutic relationship offers a safe and supportive forum for the client to build/rebuild their faith and relationship with God.
The role of counselor is not defined by the techniques used in therapy as targeting a Christian approach, but by the environment that is provided as a result of the collective efforts between therapist and client, and enhanced by Christ’s divine intervention of unconditional love and healing (Probst, 1988). The goal is for the Christian patient to seek alternative resources that promote a spiritual lifestyle, rather than just accepting spiritual process that is coming to an end. The recovering or healed patient must strive to keep right in God’s eyes and honor His Word, while remembering that God provides all that is necessary for his children. The recovering or healed patient continues to receive new life from God as learned in previous stages, lives a lifestyle that promotes faith maturity, and tries to avoid emotional, behavioral and spiritual barriers, thus contributing to continued health and healing.
And if the patient begins to falter, they must draw strength and support from the Lord to remain focused on continued emotional and spiritual health and healing (Prochaska, 1994). In conclusion, integrative therapy provides a theological and psychological approach to healing. This experiential process of combined psycho-spiritual dynamics can elicit a faith encounter with Christ that results in divine healing. As discussed, there are five primary stages of change, in addition to goals to be pursued during each stage of change. If the patient and therapist work together in each stage to recognize and combat issues that interfere with both emotional and spiritual healing, the patient will achieve divine healing. CBT for African Americans with Low Self-Esteem Cultural considerations:
Cognitive Behavioral Therapy is an ideal approach for working any individuals experiencing low self-esteem, African American females being no exception. CBT provides an easily grasped framework for understanding how the problem developed and what the maintenance factors are. It offers a proactive, goal-oriented and pragmatic approach to improving the problem (Markus ; Kitayama, 1991). Society has argued that a “culture of poverty” fosters negative attitudes among economically disadvantaged people of color towards so-called mainstream values and beliefs. This culture of poverty perspective seems to directly impact levels of self-worth and self-esteem for the individuals.
From this perspective, individuals begin to experience altered and negative beliefs and actions that are reflective of feeling unequal and inferior. These thoughts and behaviors shape the knowledge and opportunities sought after and available to different groups within society and thus, creates an additional conflict (Carspecken ; Apple, 1992). Underlying issue considerations: The first premise on which this model is built is that individuals feel the way they think. Individuals with low self-esteem are characteristically plagued by self-effacing thoughts. Self-criticism is a way of life and has a major impact on emotions and what people make of their lives. Common emotions associated with low self-esteem are sadness, anxiety, guilt, shame, humiliation, frustration and anger.
Individuals may also feel chronically discouraged and demoralized. In extreme cases low self-esteem can lead to serious depression and suicide. The second related premise and the targeted area for work focuses on bad feelings coming from illogical thoughts or distortions. Through identification of the lie behind the thoughts and developing a strong, action-oriented methodology for change, the third premise of the model is addressed as you can change the way you feel (Markus ; Kitayama, 1991). Negative automatic thoughts are automatic, involuntary thoughts that reside just below the level of consciousness. People with low self-esteem perceive many more events or situations in life as being threatening.
As a result, the automatic thoughts may be triggered excessively. Underlying conditional assumptions or rules are attitudes that are an intrinsic part of an individual’s value system or personal philosophy. Some attitudes are positive and functional, however others are destructive and can increase vulnerability to painful mood swings and interpersonal conflicts. These rules have a number of characteristics, unlike the automatic thoughts which are learned, culturally determined, idiosyncratic, rigid and resistant to change, linked to powerful emotional responses, are over-generalizations and guaranteed to perpetuate low self-esteem (Brengden, 2002).
At the heart of self-esteem lie central beliefs about oneself and one’s core ideas about the kind of person you are. These beliefs are called schemata, are usually formed in childhood and normally regarded as a statement of fact by the holder. Negative core beliefs are merely distorted opinions, based on self-perception. They become instrumental in shaping our outlook on life and reverberate on all levels. Once this core belief is activated, it produces a cognitive shift away from positive and more realistic cognitions to the negative and the person begins to systematically interpret and/or distort incoming information to fit into the schemata, or the core belief structure.
People will low self esteem will continue to think and behave in ways that will support their core belief (Brengden, 2002) Approach modifications: Low self-esteem can improve with the following approach, broken into three generalized stages. If someone has been plagued by a lack of self-esteem for a long time, the negative thoughts will have become an unrecognizable and a habitual way of thinking. The first step is to learn to notice what situations trigger the thoughts and to observe the impact that these thoughts have on emotions and behavior. Negative shifts in emotional states are often indicative of the activation of self-critical thinking (Brengden, 2002).
Uncovering automatic thoughts can be a difficult process. There are a number of tools that can be used to elicit negative thoughts more effectively with individuals with low self-esteem. These include the following: Guided discovery, role play, therapist-driven possibilities, identifying personal meanings, suggesting the opposite, in-session experiments and daily thought records. People with low self esteem set stringent and unrealistic general rules that serve as a dictate as to who they should be and how they should behave, what is acceptable and what is not, and what is necessary to establish and maintain satisfying relationships. If a minor transgression is inadvertently made, low self- steem sufferers attack themselves for not being good enough, for not doing all the things they should be doing (Beck 1979; Franklin, 2002; Corsini ; Wedding, 2000). When tackling assumptions and rules of someone with low self esteem, a first step could be to determine where the irrational thoughts come from and then examine why the thoughts and rules are unreasonable. Patients and therapists can also examine the disadvantages of adhering to these rules and exploring alternative rules which may be more healthy and rational and healthy. Looking at payoffs of obeying the rules is also important since this is a direct link to the core beliefs. This is where the vital work of improving self-esteem exists.
If the automatic thoughts, underlying assumptions and rules are addressed, they can then be analyzed, understood and modified. Through developing a strategy for change by questioning, refuting and replacing thoughts with rational, realistic and healthy ones, the habitual patterns of thinking are weakened and more adaptive thoughts and responses are introduced. Self-acceptance is enhanced too (Brengden, 2002). The next step is to examine the negative thoughts to determine whether they are healthy or unhealthy. Cognitive distortions are present in neurotic thinking patterns and once these are identified and the thoughts are seen to be unrealistic and irrational, it is much easier to work on changing them.
The types of distortions that are commonly present with individuals with low self esteem are: all-or- nothing-thinking, over-generalization, mental filter, discounting the positives, downplaying or ignoring, jumping to conclusions, mind reading, fortune telling), magnification or minimization, emotional reasoning, should statements, labeling and blame (Beck, 1979). There are a number of excellent tools that CBT practitioners can use to help someone with low self-esteem alter old destructive beliefs and create new, self-supporting beliefs. They include: examining the evidence, survey method, double standards technique, pleasure-predicting method, thinking in shades of gray, defining terms, reattribution and bringing positive qualities into focus. People with low self-esteem tend to discount their positive attributes or achievements.
Making a list of all the positive qualities and strengths can help to build and strengthen a positive view of oneself and reduce externalization of negative thoughts. The strength of the approach lies with the direct and proactive approach to attacking the source of the problem to promote healing. Once self-esteem is on the mend, the individual becomes less vulnerable to self-attack. Neutral events are less likely to be negatively misinterpreted. Negative events may not impact as powerfully. Developing healthy self-esteem can be seen as the key to discovering joy in everyday living, empowering people to make the most of their lives (Fennell, 1999). CBT for Depressed Elderly Cultural considerations:
Late-life depression is a common but under-recognized and under-treated mental illness that may impose enormous disability on patients and families. Diagnosis is often complicated by co-morbid medical illness, cognitive impairment, and adverse life events. Early intervention with a combination of education, psychotherapy, and antidepressant medication is recommended. Choice of specific agents requires consideration of symptom profile, tolerability, drug interactions, and compliance. Older patients may respond more slowly to treatment than younger patients and may more readily experience chronicity and recurrence (Sable, Dunn, Zisook, 2002). Certain types of psychotherapy also are effective treatments for depression.
Cognitive-behavioral therapy (CBT) is particularly useful. Approximately 80 percent of older adults with depression improve when they receive appropriate treatment with psychotherapy. 11Research has shown that psychotherapy is extremely effective for reducing recurrence of depression among older adults (Little, Reynolds ; Dew, 1998). Older adults exhibit many of the same symptoms as younger people with depression such as persistent sadness, social withdrawal, loss of appetite, and irritability, but they may also experience additional symptoms such as memory problems, confusion, and delusions or hallucinations, all of which can be mistaken for normal signs of aging.
Older adults often believe depression is a natural part of growing older and therefore ignore or deny their symptoms. The elderly may also be less comfortable discussing their troubles openly with family, friends, or physicians who could help them identify their illness. Despite regular visits to a primary care physician, older persons with depression may not be properly diagnosed because the symptoms occur alongside many physical ailments that receive closer attention. Finally, many older people view depression as a character flaw and worry about being stigmatized. They blame themselves for their illness and are too ashamed to get help (Knight, 1996).
Depression in older people is strongly linked to physical illnesses such as cancer, diabetes, hypertension, and Parkinson’s disease. Depression can exacerbate many physical symptoms and interfere with recovery from these illnesses, but can also be brought on by physical ailments. Specifically, strokes, hypertension, and coronary artery disease make many older individuals vulnerable to depression. Depression is also a well-known side effect of certain medications (Rigoni, 2003). Society sometimes has a mistaken idea that it is normal or expected for the elderly to feel depressed. On the contrary most older people feel satisfied with their lives yet sometimes depression develops.
Depression in the elderly can be undiagnosed and untreated thus causing needless suffering for the individual and family who could otherwise live a fruitful life. Elderly also mistakenly describe symptoms described as physical since older persons are often reluctant to discuss feelings of hopelessness, sadness, loss of interest in normally pleasurable activities, or extremely prolonged grief after a loss (Lebowitz, Pearson, Schneider, Reynolds, Alexopoulos, Bruce, Conwell, Katz, Meyers, Morrison, Mossey, Niederehe, & Parmelee, 1997) Recognizing depressive symptoms in older people are often missed, many health care professionals are learning to identify and treat the underlying depression.
If a diagnosis of depression is made, treatment with medication and/or psychotherapy will help the depressed person return to a happier, more fulfilling life. Psychotherapy is effective in reducing symptoms in short-term depression in older persons who are medically ill (Lebowitz, et al, 1997) Many elderly also experience cognitive difficulty with organizing, planning, and abstract thinking, especially by many depressed older patients. Depression in older patients is frequently associated with adverse life situations–loss of jobs, productivity, health, friends, loved ones, and homes. Major depression should always be treated as a serious illness, even if precipitated by life circumstances.
The term “reactive depression” was used to describe a depressive episode that appeared to be an expected response to trauma or adversity such as a death of a spouse or loved one, loss of a job or another unexpected or traumatic event (Sable, Dunn & Zisook, 2002). Special considerations may be necessary when working with older adults relating to such things as social and environmental context, but also looking at the developmental stages as well. Social/environmental differences are based on maturing during specific time periods, leading to a focus on generational groups such as Depression-era generation, GI Generation, Baby Boomers, rather than on specific age groups.
Developmental maturation leads to relatively minor changes, such as slowing down and the use of simpler language, but also to greater emotional complexity and a wealth of life experience upon which to draw. Specific challenges means that due to the high prevalence of chronic medical problems and neurological disorders, a higher percentage of psychological assessment and therapy is related to medical problems. There is also a higher frequency of grief work and of attention to care-giving issues. Working with elderly may require modifications because earlier born individuals have different skills, different values, and different life experiences according to the time period they were born and raised.
Specific challenges of later life all may require specific knowledge and therapeutic skills because of the problems they pose for clients, not because of the client’s age (Knight, 1996). Underlying issue considerations: According to the Diagnostic Statistical Manual-4th edition (1994), depression is described as a pattern of depressive feelings, cognitions or behaviors beginning at any age and being exhibited in a variety of contexts. Related to affect, feeling dejected, joyless, gloomy, unhappy and/or hopeless. Effected cognitions include thoughts of being inadequate, worthless, helpless, and having critical, blaming, derogatory thoughts towards self. Behaviors include worry, negative and being critical and judgmental towards others, and being prone to guilt or remorse. Depression develops from several origins.
Depressed individuals see themselves as deserving of the negativity they feel and the depreciation of their own feelings and emotions is an adaptive strategy that keeps them in a fault-finding, inferior role while placing others in a blameless, superior position. Depressives typically interpret being rejected as being their own fault and thus, internalize the rejection as the expected outcome for which they created or deserved. Depressives learn to accept the guilt and abandonment they feel over the loss by resorting to self-blame/self hatred though patterns such as taking responsibility for all that is negative or the unhealthy direction a relationship may take. Ironically, if the path the relationship takes is successful, they will readily attribute the success to the good object and detach any credit from themselves. A sense of hopelessness is also very common and can vary in degrees.
A depressed individual has adapted to feeling hopeless and unworthy and thus, has acquired their own inner dialogue with reflective language to internally describe the self or the world around them. A depressive may process distorted thoughts, and these inner cognitive distortions and ultimately, reinforce the need for defend the self to prevent further brokenness. (Josephs, 1995). By the time later adulthood arrives, depression may relate more to fear of being abandoned or rejected, being seen as unworthy, having a view of the self as being inherently bad or damaged, feeling hopelessness that allows a sense of failure and despondency to be reinforced each time something goes wrong. The client may also adhere to internal ideology that reflects the negative opinion of themselves.
This mode of thinking is what allows depressives to proceed with a pseudo-healthy life since although they are unworthy at the core, they can see themselves as being good to others. When they are confronted with criticism or loss, they inflict self-hatred or self-blame in order to explain why things happened the way they did. The depressed client internalizes loss as being their own fault, further lowering their already diminished self-esteem (Sable, Dunn ; Zisook, 2002). In order to cope with such feelings, depressives may acquire various defenses and strategies that allow them to function with such a hopeless and discouraged sense of self. The automatic thoughts of a depressive are a cycle of placing blame on themselves, rather than revealing their true feelings to a significant object.
There is an overwhelming desire for approval, recognition and/or acceptance because the fear of criticism, rejection, and being unloved is at the core of the depressive. Self-blame is necessary since by finding fault within themselves, they avoid having to express emotions. For the depressive it is safer to feel bad about themselves and what they feel then to burden another. Primary issues related to the depressive are fear of abandonment, internalizing rejection, guilt, self hatred, a sense of feeling unworthy and hopeless that connects with the fears and the over all feeling of unworthiness that keeps these behaviors, assumptions and schemas alive (Josephs, 1995). CBT Approach modifications: Psychological treatment of depression can assist the depressed individual in several ways.
First, supportive counseling helps ease the pain of depression, and addresses the feelings of hopelessness that accompany depression. Second, therapy, specifically the cognitive approach, changes the pessimistic ideas, unrealistic expectations, and overly critical self-evaluations that create depression and sustain it. Cognitive therapy helps the depressed person recognize which life problems are critical, and which are minor. It also helps him/her to develop positive life goals, and a more positive self-assessment. Third, problem-solving therapy changes the areas of the person’s life that are creating significant stress, and contributing to the depression.
This may require behavioral therapy to develop better coping skills, or Interpersonal therapy, to assist in solving relationship problems (Parker, Roy, & Eyers, 2003). More often than not, when depressed patients subject their automatic thoughts to logical principals and empirical testing, they find their hypotheses are correct, and the patient is identifying a real problem that requires a solution. Under such circumstances, the therapist should help the patient see their task as problem solving. It is important to note that the pessimistic thinking style that accompanies depression interferes with patients ability to problem solve depressed patients tend to view situations as overwhelming and hopeless.
By elaborating the problems solving process, the therapist provided patients with a strategy to offset this pessimistic thinking style. The following steps are crucial in the problem solving process: brainstorm solutions, consider the pros and cons of the solutions and choose the best solution and carry it out (Josephs, 1995). In terms of specific challenges, if the older clients are physically ill, this will pose new issues in both assessment and also in intervention with them. Sorting out physical and psychological influences on symptoms and problems is an ongoing assessment issue. Specific knowledge about the effects of different chronic illnesses as well as both the skill and emotional readiness to work with physically disabled clients become essential.
Consultation and supervised experience with psychologists who have such experience is likely to needed in addition to didactic instruction (Knight, 1996). Adapting to work with an elderly client is difficult due to the type of changes when working with clients of a different gender, ethnicity, class background, or occupation-based lifestyle. It does require sensitivity to the possibility of the difference. It also requires some knowledge of history before one was born or at least the willingness to learn that history from clients. In terms of context effects, if the work with older adults is primarily in long term care settings or in acute medical settings, the work will be specialized compared to work with healthy younger adults living and working in the community.
The differences are due to the specialized environmental context rather than to the age of the clients. It is likely to be somewhat similar to working with younger adults in medical care settings and rehabilitations settings. Learning these settings is likely to require some supervised experience working in them (Blazer, 1997). When working with clients with death and dying issues, therapists need to have basic skills in death counseling and grief work. The primary problem observed over the years is therapists failing to recognize clients need to talk about the death of loved ones sometimes even when this is the client’s stated presenting problem.
Learning to work effectively with death, dying, and grief is likely to require supervision as well as didactic instruction (Knight, 1996). Conclusion Cognitive Behavioral Therapy and cognitive restructuring is a process that begins by critically examining thought, and behavior styles, recognizing negative automatic thoughts that trigger maladaptive thoughts/behaviors, identifying more rational and realistic thought/behavior alternatives to live a more healthier and adaptive lifestyle. As a practitioner, it is essential to recognize individual issues related to ethnic, cultural and spiritual needs, and to adapt strategies and interventions to best service the client and their comprehensive needs. REFERENCES
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