PSYCHOLOGICAL THERAPIES FOR DEPRESSION
To read up on psychological therapies for depression, refer to pages 459–468 of
Eysenck’s A2 Level Psychology.
Ask yourself
 How can the behavioural approach be applied to the treatment of
depression?
 How can the cognitive approach be applied to the treatment of depression?
 Which psychological therapy do you think will be most effective for
depression?
What you need to know
PSYCHODYNAMIC
THERAPY
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Freud’s
psychoanalysis and
newer forms of
psychodynamic
therapy
Effectiveness and
appropriateness
BEHAVIOUR THERAPY
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Forms of behaviour
therapy
Effectiveness and
appropriateness
COGNITIVE AND
COGNITIVEBEHAVIOURAL THERAPY
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Beck’s cognitive
therapy
Assumptions
underlying
cognitivebehavioural therapy
Effectiveness and
appropriateness
Psychodynamic therapy
The original form of psychodynamic therapy was psychoanalysis, which was
developed by Sigmund Freud over 100 years ago. Remember Freud linked
depression to low self-esteem and excessive dependence due to over- or undergratification in the oral stage, which meant the individual was unable to cope with
loss. Consequently, Freud argued that it is crucial in therapy to uncover depressed
patients’ repressed memories and allow them to gain insight into the factors causing
their depression.
Freud used free association to gain access to the unconscious, which involves the
client saying whatever comes into his or her mind. This method often doesn’t work
very well because the client might be reluctant to say what he or she is really
thinking. However, according to Freud, long pauses in what the client says indicate
that he or she is moving close to an important repressed idea. Skilled therapists
regard the presence of long pauses as an indication that additional questioning and
discussion are required.
A second method Freud used to access the unconscious is dream analysis. He
claimed we are much more likely to gain access to repressed material while
dreaming than when we are awake because the censor in our minds that keeps the
repressed material in the unconscious does not work as well during sleep. The
repressed material is included in our dreams in a disguised or symbolic form
because of its unacceptable nature. Freud called the dream as we remember it the
manifest content and the true or underlying meaning the latent content. Dream
analysis involves interpretation of the symbols in the manifest content and
questioning clients about their dreams to work out the latent content.
Progress in therapy depends partly on transference. This involves the client
transferring onto the therapist the powerful emotional reactions previously
directed at his/her own parents or other highly significant others. These intense
feelings can be negative or positive and the client is usually unaware of what is
happening. Transference often provides a direct link back to the client’s childhood
by providing a re-creation of dramatic conflicts that were experienced at that time.
As a result, transference can facilitate the uncovering of repressed memories.
Psychodynamic therapy today has moved away from Freud’s original approach
because patients’ social relationships are considered, and current psychotherapy
does not place the same emphasis on childhood experiences that Freud did.
EVALUATION OF PSYCHODYNAMIC THERAPY
Effectiveness
 Major depressive vs. bipolar disorder. Psychodynamic therapy (in line
with most other forms of therapy) is more effective in treating major
depressive disorder than bipolar disorder.
 Strong empirical support. Traditional psychodynamic therapy was often
found to have very limited effectiveness. However, modern forms of
psychotherapy have been found to be much more effective. For example,
Leichsenring (2001, see A2 Level Psychology page 461) used the findings
from a meta-analysis to compare the effectiveness of psychodynamic therapy
and cognitive-behavioural therapy (CBT) and found in 58 of 60 comparisons
no significant differences between the two. Thus, psychodynamic therapy
may no longer compare unfavourably to CBT.
 Limited effectiveness for bipolar disorder. Colom et al. (1998, see A2 Level
Psychology page 461) compared studies in which psychodynamic therapy
and CBT therapy had been used. There was no clear evidence that either
form of therapy was effective. Sajatovic et al. (2007, see A2 Level Psychology
page 461), however, argue that the use of psychodynamic therapy with
bipolar patients makes patients better informed and more likely to continue
taking their medication. Thus, the therapy on its own has limited
effectiveness but is not without use if combined with drug therapy.
Appropriateness
 The cognitive nature of the treatment. Psychodynamic therapy focuses on
the cognitive, helping patients to change their cognitive beliefs about
themselves, and as cognitive distortions often underpin depression this
makes the nature of the therapy appropriate.
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The focus on current problems. The fact more modern forms of
psychotherapy focus on current problems again makes this treatment
appropriate.
Ignores motivational factors. Psychodynamic therapy doesn’t treat
motivational issues, which means it lacks appropriateness because many of
the problems faced by depressed patients revolve around their loss of
motivation and disengagement from the world.
Ignores behavioural problems. Doesn’t focus on patients’ behavioural
problems, such as their very low involvement in pleasurable activities.
Requires patient to be active and articulate. Psychodynamic therapy
requires patients to participate fully in complex discussions with the
therapist. They may be too passive and lacking in motivation to do this.
Slow-acting. The therapy takes a long time, which can be de-motivating for
the patient.
Drop-out rate. The fact the therapy takes time and requires the patient to be
active can lead patients to drop out because these challenges make it hard for
them to believe in the therapy, given that they are generally pessimistic in
outlook.
Less appropriate for bipolar disorder. The “talking cure” that
psychodynamic therapists provide is of limited use for the complexities of
bipolar disorder.
YAVIS. Psychodynamic therapy may work for some better than others, i.e.
young, attractive, verbally skilled, intelligent, and successful, which forms the
acronym YAVIS.
Behaviour therapy
Behaviour therapy focuses on rewarding non-depressive behaviours and not
rewarding depressive behaviour. Particular focus is given to using reinforcement to
improve depressed patients’ social skills.
Therapists use the Pleasant Events Schedule and an Activity Schedule to help clients
to set up a weekly schedule for engaging in pleasurable activities. Behavioural
activation recommended by Beck et al. (1979, see A2 Level Psychology page 463)
encourages the patient to become engaged in activities and situations that provide
reinforcement or reward and that fit in with the individual’s long-term goals. The
client schedules daily activities, rates how much pleasure and sense of achievement
are associated with each activity, and explores different forms of behaviour
designed to achieve his or her goals.
EVALUATION OF BEHAVIOUR THERAPY
Effectiveness
 Moderate effectiveness. Behaviour therapy of the kinds we have discussed
is of moderate effectiveness in treating major depressive disorder.
 Compares unfavourably with other treatments. Patients receiving
behaviour therapy often exhibit less improvement than those receiving
cognitive or drug therapy (Comer, 2001, see A2 Level Psychology page 463).
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May not work for severe depression. It has generally been argued that
behaviour therapy is mainly effective with patients who have relatively mild
depression. It is hard to see how a severely depressed patient could engage
with rating pleasurable activities.
Empirical support. Evidence suggests it may be more effective for severe
depression than previously thought. Dimidjian et al. (2006, see A2 Level
Psychology page 463) compared the effectiveness of behavioural activation
with that of cognitive therapy and drug therapy using the SSRI paroxetine.
No differences in improvement between the treatments were found for less
severely depressed patients. Behavioural activation was found to be most
effective for the severely depressed because full recovery was achieved by
56% of the patients receiving behaviour therapy compared to only 36% of
those receiving cognitive therapy and 23% of those receiving drug therapy.
Low effectiveness for bipolar disorder. Behavioural therapy is of little use
for patients in the manic phase of bipolar as they are generally already
engaged in a number of pleasurable activities.
Appropriateness
 The motivational nature of the therapy. Patients with depression have low
motivation to engage in pleasurable activities and so the treatment of this is
highly appropriate.
 Low drop-out rate. Most patients can see the value of increasing their
involvement in such activities and this encourages them to continue with
treatment.
 Ignores cognition. Behavioural treatment does not treat the cognitive
symptoms of depression, and so does not deal with the underlying problems.
 Treats symptoms not causes. It can be argued that, because the
behavioural treatment ignores cognition and just focuses on behaviour, the
treatment is superficial and so just treats the symptoms (the behaviour). This
means that symptom substitution may occur, which means that once one
maladaptive behaviour has disappeared another symptom will develop and
the depression will resurface because the underlying causes have not been
dealt with.
 Reductionism. The fact that important factors are ignored such as cognition
makes the treatment over simplistic.
Cognitive and cognitive-behavioural therapy
Aaron Beck has contributed the most towards the development of cognitive therapy
for depression. According to Beck, the negative and unrealistic beliefs of depressed
clients need to be challenged. This is accomplished through a stage process: the first
stage of cognitive therapy involves the therapist and the client agreeing on the
nature of the problem and the goals for therapy. In the next stage the client’s
negative thoughts are challenged. This involves homework assignments and
hypothesis testing. Clients typically predict that carrying out their homework
assignments will make them feel anxious or depressed, and so they are told to test
their predictions. The clients’ hypotheses are generally shown to be too pessimistic
and discovering that many of their fears are groundless speeds recovery (Beck et al.,
1979, see A2 Level Psychology page 464).
Cognitive therapists have expanded upon their original approach to include the
behavioural element thus recognising the interconnectedness of cognition, emotion,
and behaviour. Cognitive-behavioural therapy (CBT) involves a cognitive element,
challenging negative thinking, and a behavioural element, learning adaptive
behaviours. Thus, CBT recognises that it is important to focus on changing
depressed individuals’ behaviour as well as their ways of thinking about themselves
and the world around them. Kendall and Hammen (1998, see A2 Level Psychology
page 465) have identified four basic assumptions underlying cognitive-behavioural
therapy:
1. Patients’ interpretations of themselves and the world around them often differ
from what is actually the case.
2. Thoughts, behaviour, and feelings are all interrelated and so it is wrong to identify
one of these factors (e.g. behaviour) as being more important than the others.
3. Therapy needs to change the ways people think about themselves and the world
around them.
4. Therapy needs to change the client’s cognitive processes and his or her behaviour,
because the benefits will be greater than if only one element is changed.
EVALUATION OF COGNITIVE AND COGNITIVE-BEHAVIOURAL THERAPY
Effectiveness
 Strong empirical support. Elkin (1994, see A2 Level Psychology page 466)
studied depressed patients who were assigned to different treatments:
Beck’s cognitive therapy, treatment with the tricyclic antidepressant drug
imipramine, and a placebo group that received no specific treatment. 55% of
patients who completed treatment made an almost full recovery in the drug
and cognitive treatment and this was much higher than the placebo group.
Also note the findings by Hollon et al. (2005, see A2 Level Psychology page
466) in the section on drug therapy, which found drugs compared
unfavourably to CBT, thus supporting its effectiveness.
 Curative not just palliative. Research suggests that cognitive therapy is a
curative rather than a palliative treatment because it treats the underlying
causes, the faulty cognition, rather than just symptoms. Thus, it is more
effective than drug and behavioural therapy because cognitive treatment
treats causes not just symptoms. Evidence for a curative effect is provided by
Segal et al. (2006, see A2 Level Psychology page 466) who tested patients that
had recovered from depression after receiving drug and behavioural
treatment. After treatment patients were made to feel sad and those who had
previously received drug therapy showed greater negative attitudes than
those who had received cognitive-behavioural therapy. This suggests CBT
provided greater protection against relapse than drug therapy.
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Long-lasting effects. CBT produces long-lasting beneficial changes in
patients’ dysfunctional attitudes so they are relatively unlikely to relapse
back into depression.
Moderately effective for bipolar disorder. Lam et al. (2000, see A2 Level
Psychology page 467) compared patients with bipolar disorder receiving
drug therapy with patients receiving cognitive therapy and drug therapy
over a 30-month period. There were two main findings. The cognitive
therapy patients spent 12% less time than the drug-only patients in bipolar
episodes, and they reported better mood states and social functioning, and
fewer dysfunctional attitudes about goal attainment.
Reliability. Jones (2004, see A2 Level Psychology page 467) also found that
bipolar patients who received CBT had fewer depressive symptoms, better
social functioning, and a lower risk of relapse and so there is consistency
(reliability) in the evidence for CBT.
Appropriateness
 The cognitive nature of depressive symptoms. Most of the symptoms of
depression have a cognitive basis and so cognitive therapy and CBT are
appropriate to attempt to change negative and irrational attitudes into more
positive and realistic ones.
 Dual focus of CBT. CBT combines features of cognitive therapy and
behavioural therapy. As such, it is broader and more effective than either of
the forms of therapy from which it arose.
 The behavioural aspect. The behavioural element of CBT is appropriate in
that it also focuses on increasing depressed patients’ involvement in
pleasurable and rewarding activities.
 Cognitions may be realistic rather than faulty. The depressed person’s
beliefs may be realistic and so not cognitive distortions. Maybe the person’s
economic prospects are not good or they struggle with relationships because
they lack social skills, and so treatment is not as straightforward as changing
faulty cognitions.
 The effects of changing faulty cognitions may be exaggerated. Those who
advocate Cognitive Behavioural Therapy may exaggerate the importance of
cognitive processes. Many clients develop more rational and less distorted
ways of thinking about important issues with no beneficial changes in their
maladaptive behaviour.
 Insufficient consideration of personal relationships. Cognitive and
cognitive-behavioural therapists don’t consider these relationships
sufficiently, which is a weakness because these are often at the heart of the
depressed person’s problems.
 Relapse rates. Many depressed patients do relapse, which suggests that the
therapy might simply suppress patients’ negative and dysfunctional beliefs
rather than eliminating them. This does question how much the treatment is
curative but on the other hand relapse rate are usually lower with than other
forms of treatment.
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Less invasive than biological therapies. CBT does not have the same
undesirable side effects as biological treatments and so on these grounds
alone some would prefer to use this therapy.
So what does this mean?
Any comparisons of the effectiveness of different treatments should be treated with
caution as it is difficult to know if differences are due to the actual therapy or the
individual differences of the patient or therapist. Therapy depends in part on the
skills of the therapist and so differences in improvement may be due to such
differences rather than the treatment itself. The fact that patients usually choose
their own treatment and so are a self-selected sample also complicates comparisons
of treatments. Moreover, recovery may not be due to the specific nature of the
treatment but to general factors that underpin all treatments, such as the effect of
having someone sensitive to talk to and being able to express all worries and fears,
which is known as the “general therapy effect”.
Assessing the effectiveness of treatments is further complicated by the “hello–
goodbye effect” whereby patients overestimate their symptoms at the start of
treatment and underestimate their symptoms at the end. Another issue is
publication bias whereby significant findings are published more than nonsignificant ones. These biases may make therapies appear more effective than they
really are. Imagine if all the findings that a therapy doesn’t work are suppressed,
then of course it’s going to appear effective!
Ethical issues raise further concerns as can the patient really give fully informed
consent? A number of things can limit this, such as the patient not being provided
with enough information about the treatment, they may not remember the
information accurately, and they may agree just because they respect the therapist
rather than understand the treatment.
However, in spite of all of these issues it is important to understand as best we can
the effectiveness and appropriateness of therapies because treatment is usually
better than no treatment, even if part of the improvement is a placebo effect. The
psychological therapies do show there is more to treatment than just drugs for
depression. However, many would consider the optimal approach to treatment is a
multi-dimensional one in which drugs are combined with one or more other
treatments. However, on the other hand, given that CBT is more curative than other
therapies and doesn’t have the unpleasant side effects that biological therapies have,
many may prefer to opt for this.
Over to you
(a) Outline one or more psychological therapy(ies) for depression. (9 marks)
(b) Evaluate the therapy(ies) described in (a). (16 marks)