Denise is described as having nonchronic depression,? which appeared most recently at the onset of her husband’s brain cancer diagnosis. Her symptoms were loneliness, difficult

think of rational responses more readily with practice.

Another problem deriving from the misap- plication of cognitive therapy techniques oc- curs when the therapist uses a particular tech- nique inflexibly. It is often necessary for the therapist to try out several behavioral or cogni- tive techniques before finding an approach to which a patient responds well. The cognitive therapist must stay with a particular technique for a while to see whether it works, but he or she must also be willing to try an alternative technique when it becomes apparent that the patient is not improving. To give a specific ex- ample, behavioral homework assignments are sometimes more helpful with particular pa- tients, even though the therapist has every rea- son to predict in advance that cognitive assign- ments will be more effective.

In some instances in which it appears that lit- tle progress is being made in therapy, it turns out that the therapist has selected a tangential problem. The cognitive therapist should be alert to this possibility, especially during the early stages of therapy. When there appears to be little or no significant change in depression level, even when the patient seems to have made considerable progress in a problem area, the therapist should consider the possibility that the most distressing problem has not yet been uncovered. A typical example of this kind of difficulty is the patient who presents diffi- culty at work as the major problem, when it turns out that couple problems are contribut- ing significantly to the work difficulties. The real issue may be withheld by the patient be- cause it seems too threatening.

Finally, cognitive therapy is not for everyone. If the therapist has tried all available ap- proaches to the problem and has consulted with other cognitive therapists, it may be best to refer the patient to another therapist with ei- ther the same or a different orientation.

Regardless of why therapy is not progressing satisfactorily, cognitive therapists should at- tend to their own affect and cognitions. They must maintain a disciplined, problem-solving stance. If the cognitive therapist finds him- or herself unduly influenced by a patient’s despair or begins to notice that his or her own schemas are triggered by therapeutic interactions, he or she should seek supervision. Hopelessness in patients or therapists is an obstacle to problem solving. If therapists can effectively counteract their own negative self-assessments and other

dysfunctional thoughts, they will be better able to concentrate on helping patients find solu- tions to their problems.

Case Study of Denise: Nonchronic Depression

In the case study that follows, we describe the course of treatment for a nonchronically de- pressed woman seen at our center. Through the case study, we illustrate many of the concepts described earlier in this chapter, including elici- tation of automatic thoughts, the cognitive triad of depression, collaborative empiricism, structuring a session, and feedback.

Assessment and Presenting Problems

At the initial evaluation, Denise reported that she was a 59-year-old widow, who had been living alone for the last year. Denise’s husband had been diagnosed with brain cancer three years prior and died approximately one year ago. She had two grown unmarried children (27 and 25 years old) who were pursuing ca- reers in other parts of the country. Denise had an undergraduate degree and had worked until age 30 but stopped after marrying. Denise de- scribed her major problems as depression (over the last year and a half), difficulty coping with daily life, and loneliness. She reported one prior episode of major depression around age 25, following the death of her father.

Denise said she had become increasingly so- cially isolated with the onset of her husband’s illness (brain cancer). She reported having had normal friendships as a child, teenager, and young adult. She and her husband had led a rel- atively quiet life together, mostly focused on raising their children and respective work. When they had free time, they had enjoyed in- tellectual and cultural activities together (muse- ums, lectures, concerts, and fine restaurants). They had a few close friends with whom they socialized but those friends had retired in Florida and Arizona during the time of the hus- band’s illness.

Denise was diagnosed with a major depres- sive disorder, recurrent, on Axis I. Her test scores verified the diagnosis of depression. Denise’s Beck Depression Inventory (BDI) score was 28, placing her in the moderate to severe range of depression. Her most prominent de- pressive symptoms included loss of pleasure, ir- ritability, social withdrawal, inability to make

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decisions, fatigue, guilt, difficulty motivating herself to perform daily functions, and loneli- ness.

Session I

The session began with Denise describing the “sad feelings” she was having. The therapist al- most immediately started to elicit Denise’s au- tomatic thoughts during these periods.

THERAPIST: What kind of thoughts go through your mind when you’ve had these sad feel- ings this past week?

DENISE: Well, I guess I’m thinking what’s the point of all this. My life is over. It’s just not the same. I have thoughts like, “What am I going to do? Sometimes I feel mad at him, you know, my husband. How could he leave me? . . . Isn’t that terrible of me? What’s wrong with me? How can I be mad at him? He didn’t want to die a horrible death. I should have done more. I should have made him go to the doctor when he first started getting headaches. . . . Oh, what’s the use?

THERAPIST: It sounds like you are feeling quite bad right now. Is that right?

DENISE: Yes.

THERAPIST: Keep telling me what’s going through your mind right now?

DENISE: I can’t change anything. It’s over. I don’t know. . . . It all seems so bleak and hopeless. What do I have to look forward to . . . sickness and then death?

THERAPIST: So one of the thoughts is that you can’t change things, and that it’s not going to get any better?

DENISE: Yes.

THERAPIST: And sometimes you believe that completely?

DENISE: Yeah, I believe it, sometimes.

THERAPIST: Right now do you believe it?

DENISE: I believe it—yes.

THERAPIST: Right now you believe that you can’t change things and it’s not going to get better?

DENISE: Well, there is a glimmer of hope, but it’s mostly . . .

THERAPIST: Is there anything that you kind of look forward to in terms of your own life from here on?

DENISE: Well, what I look forward to . . . I en- joy seeing my kids, but they are so busy right now. My son is a lawyer and my daughter is in medical school. So, they are very busy. They don’t have time to spend with me.

By inquiring about Denise’s automatic thoughts, the therapist began to understand her perspective—that she would go on forever, mostly alone. This illustrates the hopelessness about the future that is characteristic of most depressed patients. A second advantage to this line of inquiry is that the therapist introduced Denise to the idea of looking at her own thoughts, which is central to cognitive therapy.

As the session continued, the therapist probed Denise’s perspective regarding her daily life. The therapist chose to focus on her inactiv- ity and withdrawal. This is frequently the first therapeutic goal in working with a severely de- pressed patient.

In the sequence that follows, the therapist guided Denise to examine the advantages and disadvantages of staying in her house all day.

DENISE: Usually I don’t want to leave my house. I want to stay there and just keep the shades closed; you know, I don’t want to do anything. I just want to keep everything out, keep everything away from me.

THERAPIST: Now do you feel better when you stay in the house all day trying to shut every- thing out?

DENISE: Sort of . . .

THERAPIST: What do you mean?

DENISE: Well, I can watch TV all day and just lose myself in these silly shows. I feel better when I see other people and their problems on these shows. It makes me feel less lonely and like my problems aren’t so bad.

THERAPIST: And so how much time do you spend doing that?

DENISE: Now, lately? . . . Most of the time. Staying inside and watching TV feels safe, sort of secure, everything . . . like my loneli- ness, feels more distant.

THERAPIST: Now after you have spent some time like this, how do you feel about your- self?

DENISE: Afterwards? I usually try not to pay much attention to how I’m feeling.

THERAPIST: But when you do, how do you feel?

Cognitive Therapy for Depression 279

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DENISE: I feel bad. I feel bad for wasting the day. I don’t get to things that I need to take care of . . . like my bills, like cleaning, like taking a shower. I usually end up feeling kind of pathetic . . . and guilty.

THERAPIST: On the one hand you seem to feel soothed and on the other hand, afterwards, you’re a bit critical of yourself?

Note that the therapist did not try to debate or exhort Denise to get out of the house or be- come involved with necessary daily tasks. Rather, through questioning, the therapist en- couraged her to examine more closely her as- sumption that she was really better off watch- ing TV all day in her house. This is the process we call “collaborative empiricism.” By the sec- ond session, Denise had reexamined her hy- pothesis about watching TV and remaining in the house all day.

DENISE: About watching TV in the house ver- sus getting out, I thought about that the other day. I remember telling you that it made me feel better to stay there. When I paid attention to what I really felt, it didn’t make me feel better. It just kind of blocked out feeling bad, but I didn’t feel better.

THERAPIST: It is funny then that when you talked about it, your recollection of the ex- perience was more positive than it actually was, but that sometimes happens with peo- ple. It happens to me too. I think that some- thing is good that’s not so hot when I actu- ally check it out.

We now return to the first session. After some probing by the therapist, Denise men- tioned that it sometimes feels like cognitive therapy “is my last hope.” The therapist used this as an opportunity to explore her hopeless- ness and suicidal thinking.

THERAPIST: What was going through your mind when you said, “This is my last hope”? Did you have some kind of vision in your mind?

DENISE: Yeah, that if this doesn’t work, I feel like I couldn’t take living like this the rest of my life.

THERAPIST: If it doesn’t work out, then what?

DENISE: Well, I don’t really care what happens to me . . .

THERAPIST: Did you have something more con- crete in mind?

DENISE: Well, right this minute I don’t think I could commit suicide, but if I keep feeling this way for a long time, maybe I could. I don’t know, though—I’ve thought about sui- cide before, but I have never really thought about how I would do it. I know certain things stop me, like my kids. I think it would really hurt them and some other people too, like my mother. My mom is in good health now, but she may need me some day. . . . Yeah, those are the two things that stop me, my children and my mother.

THERAPIST: Now those are the reasons for not committing suicide. Now what are some of the reasons why you might want to, do you think?

DENISE: Because sometimes it just feels so empty and hopeless. There’s nothing to look forward to—every day is the same. My life is such a waste, so why not just end it?

The therapist wanted Denise to feel as free as possible to discuss suicidal thoughts; thus, he tried hard to understand both the reasons for her hopelessness and the deterrents to suicide. After determining that she had no imminent plans to make an attempt, the therapist said that he would work with her to make some changes. He then asked her to select a small problem that they could work on together.

THERAPIST: Now are there any small things that you could do that would affect your life right away?

DENISE: I don’t know. Well, I guess just calling my friend Diane in Florida. She called about a month ago and then again last week. Both times I told her I was busy and would call her back, but I haven’t. I’ve felt so down. I have nothing to say to her.

THERAPIST: Well, when she lived in the area, what kinds of things did you talk about?

DENISE: We have kids about the same age, so we would talk about our kids. We both like to read and we used to go to a book club together—so we would talk about the books we were reading. Both of us liked art. We used to attend lectures at the museum during the week, so we would talk about art and the lectures. We would spend time making plans to do things together in our free time. It al-

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ways was very interesting when I spent time and with her. We had so much in common. I do miss her.

THERAPIST: It sounds like you used to be in- volved in a number of interesting activities. What about now?

DENISE: After my husband got sick and then my friends moved, I just stopped. I haven’t done any of those things in quite a while.

THERAPIST: What do you think about attending a lecture series now?

DENISE: I don’t know.

THERAPIST: Well, what do you think about that idea?

DENISE: It’s an OK idea, but it just seems like too much. I don’t think I’ll enjoy it . . . the way I feel . . . I don’t know.

THERAPIST: Would you be willing to test out that thought that you won’t be able to enjoy it now?

DENISE: I don’t know . . . I guess so.

THERAPIST: Is that a “yes”?

DENISE: Yes, but I don’t see how I’m going to get myself to do it.

THERAPIST: Well, how would you go about finding out about a lecture series?

DENISE: You look online at the museum’s website to see what’s available.

THERAPIST: OK. Do you have a computer?

DENISE: Yes.

THERAPIST: Is it working?

DENISE: Yes.

THERAPIST: How do you feel about doing that?

DENISE: I guess I could do that. . . . I’m so pa- thetic, I know what to do. I don’t need you to spell it out for me. Why didn’t I just do this before?

THERAPIST: Well, you probably had good rea- sons for not doing it before. Probably you were just so caught up in the hopelessness.

DENISE: I guess so.

THERAPIST: When you are hopeless you tend to deny, as it were, or cut off possible options or solutions.

DENISE: Right.

THERAPIST: When you get caught up in hope- lessness then, there is nothing you can do. Is that what you think?

DENISE: Yeah.

THERAPIST: So, then, rather than be down on yourself because you haven’t looked this up online before, why don’t we carry you right through?

This excerpt illustrates the process of graded tasks that is so important in the early stages of therapy with a depressed patient. The therapist asked the patient a series of questions to break down the process of attending a lecture series into smaller steps. Denise realized that she had known all along what to do, but, as the thera- pist pointed out, her hopelessness prevented her from seeing the options.

DENISE: Taking this step is going to be hard for me.

THERAPIST: First steps are harder for every- body, but that’s why there is an old expres- sion: “A journey of a thousand miles starts with the first step.”

DENISE: That’s very true.

THERAPIST: It’s the first step that is so very im- portant, and then you can ready yourself for the second step, and then the third step, and so on. Eventually, you build up some mo- mentum, and each step begins to follow more naturally. But first, all you have to do is take one small step. You don’t have to take giant steps.

DENISE: Well, yeah, I can see that. I guess I was thinking every step was just as hard as the first. Maybe it will get easier.

In the second session, Denise reported success.

DENISE: I checked online about the lecture se- ries and I surprised myself. One actually sounded interesting, and I’m thinking that I might just register for it online. I really didn’t think any of those feelings were still there. I’m kind of looking forward to that next step.

At the end of the first session, the therapist helped Denise fill out the Weekly Activity Schedule for the coming week. The activities were quite simple, such as getting up and tak- ing a shower, fixing meals, going out shopping, and checking out the lecture series online. Finally, the therapist asked Denise for feedback about the session and about her hopelessness.

Cognitive Therapy for Depression 281

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THERAPIST: Do you have any reactions?

DENISE: I’m still feeling down, but I’m also feel- ing a little better. It’s interesting that just the idea of looking at what lecture’s might be available is making me feel a little lighter. I even had the thought of calling Diane to talk over the options. . . . Is this a sign of better things to come?

THERAPIST: What do you think?

DENISE: Maybe.

Session 2

In the second session, the therapist began by collaborating with Denise to set an agenda. Denise wanted to discuss the fact that she had not been attending to her bills or to her house- work and was still spending a good part of the day alone in front of the TV; the therapist uti- lized this as an opportunity to discuss the issue of activity versus inactivity on the agenda. They then reviewed the previous homework. Denise had carried out all the scheduled activi- ties and had also listed some of her negative thoughts in between sessions. Her BDI score had dropped somewhat. (Patients routinely fill out the BDI before each session, so that both the patient and the therapist can monitor the progress of treatment.)

Denise then shared her list of negative thoughts with the therapist. One concern was that she had expressed angry feelings about her husband during the first session.

DENISE: I don’t like revealing things about my- self, but you told me to write down my thoughts. So here it is. When I went to bed the night after of our first session, I thought about what I said to you, you know, about being angry at my husband. I was thinking that you probably think I am this really harsh and cold person. I mean, here my hus- band died this horrible death and I have this hard, insensitive reaction. I started thinking that now you probably feel really negatively toward me because of that statement and that you don’t want to work with me.

THERAPIST: I’m really glad you’re telling me these thoughts. Let me start by asking you who is having these negative thoughts?

DENISE: You? Well, no. Actually, it’s me.

THERAPIST: Right. Do you think that someone

like me might have another reaction to what you said?

DENISE: I don’t know. I mean it is pretty harsh being angry at someone who had no control over what was happening.

The therapist then offered Denise an alterna- tive perspective:

THERAPIST: Do you think that someone might react to your statements with empathy?

DENISE: How could they?

THERAPIST: I imagine it would be very upsetting and annoying to have lost both your hus- band and your friends—all around the same time. Even though you love and care about all of them, feeling angry is understandable. It sounds like a basic human reaction to some very difficult life events.

DENISE: Yeah, I guess that does make sense. Thanks.

This illustrates how a cognitive therapist can utilize events during the session to teach a pa- tient to identify automatic thoughts and to con- sider alternative interpretations. In addition, the therapist provided a summary of a key theme he had identified from listening to Denise’s automatic thoughts about her hus- band and about therapy. The theme was her fear of being harshly judged and potentially punished for her statement (punitiveness schema). Cognitive therapists often identify and begin to correct EMSs during the first phase of treatment. More intensive work on changing schemas in a later phase of treatment may be required to inoculate against relapse. We elaborate on this process in the next section of this chapter. In the segment that follows, the therapist explained how he arrived at the con- clusion that punitiveness was an important schema for Denise.

THERAPIST: When you said that you thought I would have a negative opinion about you and not want to work with you because you said you felt angry at your husband, it sounded as though you were really con- cerned that you would be harshly judged and punished for your statements.

DENISE: Yes, that’s right.

THERAPIST: I don’t want to make too much out of this at the moment, but you also said that

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after your friends had moved, you felt angry at them and judgmental of their decision. Even though you knew that each set of friends had to move for specific financial or health reasons and they had been in the pro- cess of completing their moves over several years, part of you still felt very angry with them. You mentioned that you strongly be- lieve that friends should be there for each other, especially in times of great need, and if a friend lets another friend down, that rela- tionship should end. Is that right?

DENISE: Right.

THERAPIST: So here, you largely have with- drawn from these important relationships and now you’re feeling quite lonely. The thought of talking to these friends again brings fears that they will now be angry and punitive with you for your reaction to them. You’re caught in a no-win situation. Is that right?

DENISE: Yes, that sounds right.

THERAPIST: So one of the things that can really grab hold of you—and make you feel terrible—is this notion that people, including yourself, should behave in specific ways, and if they or you don’t behave the “right” way, then harsh punishment should result. Is that correct?

DENISE: Yes, that sounds right. But hearing you say it makes me realize that it doesn’t really sound right.

THERAPIST: What do you mean?

DENISE: It’s too extreme. It’s too harsh. People are human and they have limitations and they make mistakes sometimes.

THERAPIST: It’s good that you are starting to notice and evaluate these thoughts rather than just responding to them automatically. What this tells us is that you have to be alert for whenever you have the sense that either you or others should be strongly punished for not behaving in a specified way. The idea that people should not be cut a break, even under very difficult circumstances, may not work very well in real life with real people. You mentioned that both friends told you they felt terrible about leaving you at this time, and both have called you regularly since leaving the area. Do you think that if you begin to respond to and return their calls, they might react differently—in the

same way that I reacted differently from what you expected?

DENISE: Yes, that is very likely.

About halfway through the session, the ther- apist asked the patient for feedback thus far:

THERAPIST: Now at this point, is there anything that we have discussed today that bothered you?

DENISE: That bothered me?

THERAPIST: Yeah.

DENISE: I feel like I’m a bit of a freak.

THERAPIST: That is important. Can you . . .

DENISE: Well, I’m trying not to feel that way, but I do.

THERAPIST: Well, if you are, you are. Why don’t you just let yourself feel like a freak and tell me about it?

DENISE: Well, I’m feeling like I’m just so differ- ent from everyone else. Other people don’t seem to have my problems. They’re still hap- pily married and carrying on with life. I just feel so different from everyone.

This comment led to identification of a third theme, the social isolation/alienation schema. Denise had been viewing herself as increasingly different for the past couple of years. By this point, however, she was beginning to catch on to the idea of answering her thoughts more ra- tionally. After the therapist pointed out the negative thought in the preceding excerpt, the patient volunteered:

DENISE: I know what to do with the thought “I’m a freak.”

THERAPIST: What are you going to do with it right this minute?

DENISE: I am going to say to myself, “I’m not so different from other people. Other people have lost their mates. I’m not the only one. I’m just the first one in my group of friends. Eventually, they will all have the same situa- tion as me. It’s just a part of life.” Seeing you for help doesn’t mean I’m a freak. You prob- ably see lots of people and help them with problems like mine.

THERAPIST: Right.

The same automatic thoughts arose later in the session, when Denis

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