231

Cognitive-Behavioral Treatment of Depression:

A Three-Stage Model to Guide Treatment Planning
J a m e s c . O v e r h o l s e r , Case Western Reserve University

This article describes a three-stage model that can be used to guide the cognitive-behavioral treatment of depression. During the first
stage, the therapist establishes a sound therapeutic alliance, conducts a thorough assessment of depression, and uses differential di-
agnosis to guide the preliminary treatment plan. During the second stage, a series of modules are used to match the treatment plan
with the particular needs of each client. The modules target different areas that are often related to depression: reduced activity, social
impairment, ineffective coping, cognitive biases, problem-solving deficits, and inadequate self-esteem. During the third stage, de-
pressed clients can learn specific strategies to reduce the risk of relapse and manage the possible recurrence of depressive feelings. The
three-stage model promotes an integration of treatment strategies and allows the therapist to provide a structured treatment plan that
remains responsive to the needs of each particular client.

ANY TREATMENTS are available for depressed cli-
M ents. The NIMH Treatment of Depression collab-
orative study (Elkin et al., 1989) c o m p a r e d cognitive
therapy, interpersonal therapy, antidepressant medica-
tions, and drug placebo. Results showed that all treat-
ments were useful, with few differences between treatments.
None of these treatments was clearly effective with a ma-
jority of clients. Furthermore, at the time of the 18-
m o n t h follow-up, most patients had improved, but rela-
tively few had recovered (Shea et al., 1992). Instead of
competing against each other, it may be better to com-
bine and integrate different treatment strategies in order
to maximize the potential benefits to clients. Most clients
have problems that could benefit from an integration of
different interventions (Craighead, 1980; Hersen, 1981).
There is a current emphasis on empirically supported
therapies (Chambless & Hollon, 1998). A useful treat-
ment should be capable of replication, with different clients
receiving therapy from different therapists. Treatment
manuals have been developed to facilitate the ability of
different therapists to provide the same treatment. Un-
fortunately, psychotherapy in the clinic often differs from
the way that psychotherapy is administered in research
settings (Silverman, 1996). Treatment manuals are based
on nomothetic guidelines, whereas psychotherapy treat-
m e n t plans follow a flexible, idiographic approach (Per-
sons, Bostrom, & Bertagnolli, 1999). The therapist should
adapt treatment to the unique needs of each client (Rush
& Shaw, 1983). Most treatment manuals follow one ap-
Cognitive and Behavioral Practice 10, 2 3 1 - 2 3 9 , 2003
1077-7229/03/231-23951.00/0
Copyright © 2003 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
proach to therapy, largely ignoring the broader literature
on treatment of depression. "Pure" forms of treatment
are often not realistic in most applied clinical settings.
Furthermore, many treatment manuals describe a session-
by-session focus that seems too rigid for most clinical set-
tings. Strict adherence to a therapy manual is likely to
impair the therapeutic relationship (Castonguay et al.,
1996; Strupp & Anderson, 1997) and reduce the effec-
tiveness of therapy. Ideally, therapists can strike a middle
g r o u n d between unstructured therapy and rigid adher-
ence to a manual (Eifert, Schulte, Zvolensky, Lejuez, &
Lau, 1997; Kendall, Chu, Gifford, Hayes, & Nauta, 1998).
Depression is a complex disorder involving many dif-
ferent factors (Craighead, 1980). Different clients have
different needs in therapy (Heiby, 1986, 1989; Nelson-
Gray, Herbert, Herbert, Sigmon, & Brannon, 1989). Two
clients can meet diagnostic criteria for major depression
yet may require different elements in their treatment. In
her work with depressed outpatients, Heiby has shown
that depressed clients respond best when therapy is de-
signed to match their particular needs. Therapy was most
effective when the treatment was designed to address a
specific deficit in the client (e.g., self-control problems vs.
social skills deficits). Similar to the way that a psychiatrist
would not use a fixed dose of one medication to treat all
clients, a psychotherapist needs a range of interventions
to guide treatment.
Cognitive-behavioral therapy provides a broad frame-
work that can incorporate many different treatment strat-
egies. Cognitive-behavioral therapy includes a n u m b e r of
empirically supported treatments that have been f o u n d
effective for clients with major depression. In a recent
series o f articles (Overholser, 1995a, 1995b, 1995c, 1996a,
1996b, 1996c), semi-independent treatment modules
have b e e n used to provide a framework for guiding the
232 Overholser
t r e a t m e n t o f depression. A similar a p p r o a c h was recently
p r o p o s e d for the t r e a t m e n t of b i p o l a r d i s o r d e r (Henin,
Otto, & Reilly-Harrington, 2001). T h e use o f different
t r e a t m e n t m o d u l e s can help the therapist to plan specific
interventions for o v e r c o m i n g depressive tendencies and
tailor the t r e a t m e n t plan to the u n i q u e needs of each
client. The m o d u l e s can integrate a variety o f treatments
that have b e e n s u p p o r t e d by empirical research. The
t r e a t m e n t m o d u l e s provide a structured a n d empirically
s u p p o r t e d t r e a t m e n t plan that still allows the therapist to
r e m a i n flexible a n d responsive to the different needs of
different clients.
T h e r a p y rarely progresses in a simple l i n e a r fashion.
T r e a t m e n t goals shift over the course o f t h e r a p y (Over-
h o l s e r & Spirito, 1990). T h e p r e s e n t article describes
the use o f t r e a t m e n t m o d u l e s , i n c o r p o r a t e d into a com-
p r e h e n s i v e plan for t r e a t m e n t . T h e p r o p o s e d treat-
m e n t m o d e l uses t h r e e stages to reflect d i f f e r e n t issues
that are p r o m i n e n t at d i f f e r e n t points in t h e r a p y (see
F i g u r e 1). T h e p r o p o s e d t r e a t m e n t m o d e l allows thera-
pists to c o n c e p t u a l i z e the t r e a t m e n t o f most d e p r e s s e d
c l i e n t s as it evolves over time. T h e t h e r a p y m o d u l e s
allow the t h e r a p i s t a d e q u a t e flexibility to vary the
a m o u n t of time s p e n t on d i f f e r e n t issues. Some target
areas may r e q u i r e extensive time o r r e p e t i t i o n b e f o r e
a d e q u a t e p r o g r e s s has b e e n observed. However, o t h e r
t a r g e t areas may be a d d r e s s e d quickly or n o t at all for a
p a r t i c u l a r client.
Stage One: Initial Evaluation and
Engagement in Therapy
Depressed clients often seek therapy when feeling
their worst. These clients n e e d a compassionate therapist
who can listen to their problems, u n d e r s t a n d their dis-
Stage 1 Stage 2 Stage 3
Target Areas
Reduced Social
Actlvlty Impairment
Alliance, [ , .
Assessment)i--- ~ Ineffectlve Cognitive I Relapse
Coping Biases Prevention
Diagnosis I
Problem- Inadequatei
Solving Self-Esteem
Deficits
Figure I. A three-stage model to guide the treatment of
depression.
tress, a n d help redirect their c u r r e n t trajectory. T h e core
elements n e e d e d at the start o f therapy include establish-
ing a therapeutic alliance, c o n d u c t i n g a t h o r o u g h assess-
ment, a n d using differential diagnosis to guide the pre-
liminary t r e a t m e n t plan (Overholser, 1995a). D u r i n g the
first stage o f therapy, the t h e r a p i s t addresses the same
basic p r e l i m i n a r y issues with all clients.
T h e therapist must establish a s o u n d therapeutic alli-
ance with each depressed client (Overholser & Silver-
man, 1998). The therapeutic relationship is largely estab-
lished by events that occur during the first therapy session
(Sexton, Hembre, & Kvarme, 1996). Because many de-
pressed clients r e p o r t difficulties m a i n t a i n i n g close inter-
personal relationships, it is essential for the therapist to
provide a safe a n d supportive a t m o s p h e r e that is based
on trust a n d acceptance. A strong therapeutic relation-
ship is especially i m p o r t a n t for d e p r e s s e d clients who dis-
play tendencies for excessive i n t e r p e r s o n a l d e p e n d e n c y
(A. T. Beck, 1983). T h e therapist must take the time to lis-
ten to the client's e m o t i o n a l pain in o r d e r to u n d e r s t a n d
how the depressed client feels i n c o m p e t e n t , inadequate,
or rejected. T h e therapist can convey the attitude that no
p r o b l e m is u n b e a r a b l e , unsolvable, o r i n s u r m o u n t a b l e .
T h e therapist remains accepting, u n d e r s t a n d i n g , a n d
caring, even d u r i n g stressful times. T h e t h e r a p e u t i c alli-
ance should be m a i n t a i n e d t h r o u g h o u t all sessions with
all clients.
Early in treatment, the therapist should e n c o u r a g e ac-
tive collaboration with the client in o r d e r to h e l p r e d u c e
the client's t e n d e n c y for helpless passivity. T h e therapist
can educate the client a b o u t depression in terms o f its
symptornatology, course, and treatment (J. S. Beck, 1995).
Clients should u n d e r s t a n d the anticipated d u r a t i o n of
treatment, the type o f activities to be c o n d u c t e d d u r i n g
therapy, a n d the likely effectiveness o f t r e a t m e n t (Beut-
let, Clarkin, & Bongar, 2000). A s o u n d e x p l a n a t i o n a n d
rationale for therapy instills h o p e a n d p r o m o t e s early im-
p r o v e m e n t in depressed clients (Ilardi & Craighead,
1994). Also, the d e g r e e to which clients accept the ratio-
nale for t r e a t m e n t predicts a g o o d o u t c o m e from cogni-
tive therapy (Moorey, 1989). Some clients r e p o r t initial
feelings o f relief once therapy has b e e n initiated. These
temporaI T i m p r o v e m e n t s can provide a starting p o i n t for
h o p e a n d change.
During the initial evaluation, m u c h time is focused on
the assessment o f depression a n d suicide risk. Assessment
serves a variety of functions, including: d o c u m e n t i n g the
client's diagnosis, evaluating the severity o f depression,
developing ideas for a preliminary t r e a t m e n t plan, moni-
toring the client's progress over time, evaluating the ef-
fectiveness of treatment, a n d readjusting the t r e a t m e n t
plan as n e e d e d . Thus, some form o f assessment should be
part o f the o n g o i n g care o f each client.
T h e assessment o f depression may be facilitated by the
 CBT of Depression
use of structured interview measures, such as the Hamil-
ton Rating Scale for Depression (Hamilton, 1960) or a
variation (e.g., Miller, Bishop, Norman, & Maddever,
1985). When working with depressed youth, the therapist
can use the Children's Depression Rating Scale-Revised
(Poznanski, Cook, & Carroll, 1979) or its short form
(Overholser, Brinkman, Lehnert, & Ricciardi, 1995). Use-
ful self-report measures include the Beck Depression In-
ventory (A. T. Beck, Ward, Mendelson, Mock, & Erbaugh,
1961), the Zung Self-Rating Depression Scale (Zung,
1965), the CES-D Scale (Radloff, 1977), the Children's
Depression Inventory (Kovacs, 1981), and the Geriatric
Depression Scale (Yesavage et al., 1983).
Self-monitoring forms can be useful in the initial and
ongoing assessment of depression. Some depressed cli-
ents report feeling depressed "all the time." However, a
simple daily recording form can help clients notice
changes in their moods throughout the week. Clients can
be asked to record their mood type (e.g., happy, sad,
mad) and mood intensity (e.g., 0 to 10) at least three
times each day (Overholser, 1995a). Such ongoing tracking
of mood states can help clients bypass mood-dependent
recall and reduce the tendency to overgeneralize when
asked about symptoms that occurred during the previous
week. In addition, self-monitoring forms can help clients
identify patterns over time, days, or activities. Later in
treatment, simple self-monitoring forms can be expanded
to include information about situational triggers or inter-
personal consequences related to depressed or irritable
moods. These additional factors may be addressed in sub-
sequent sessions.
The therapist needs to establish a diagnosis of major
depression according to the current diagnostic criteria
(American Psychiatric Association, 2000). A central part
of the initial assessment involves the differential diagno-
sis of depressive symptoms and syndromes. Differential
diagnosis can help to guide the development of the pre-
liminary treatment plan. The therapist can evaluate the
client's current diagnosis and refer for medications when
the depressive symptoms are best accounted for by a diag-
nosis of bipolar disorder, major depression with psychotic
features, or major depression with melancholia (Over-
holser & Schubert, 1996). When clients present with
symptoms of melancholia, they are likely to benefit from
antidepressant medications (Nelson, Mazure, Quinlan, &
Datlow, 1984) or electroconvulsive therapy (Carney, 1986).
Also, medications are likely to be helpful when clients re-
port a personal or family history of positive response to
prior treatments using medications (Stern, Rush, & Men-
dels, 1980). Finally, it is useful to refer to a psychiatrist
when clients request medications as their preferred mode
of treatment.
As part of the initial evaluation, the therapist should
develop a preliminary treatment plan. Therapist and cli-
233
ent can identify several goals for treatment, emphasizing
the value of building competence in areas that can help
reduce depressive tendencies. Cognitive factors often
play a central role in understanding depression and its
treatment (Alford & Beck, 1997; A. T. Beck, Rush, Shaw,
& Emery, 1979). For many clients, cognitive factors can
be seen as a primary determinant of emotion and behav-
ior (A. T. Beck, 1983; J. S. Beck, 1995). Biased informa-
tion processing can influence other aspects of depression
(A. T. Beck, 1987), including maladaptive coping, limited
social functioning, and a negative view of self. Changing
cognitions can promote changes in emotions and behav-
iors. Thus, a cognitive conceptualization can provide a
framework to guide the ongoing processes of understand-
ing the client's problems and planning the best treatment
(J. S. Beck, 1995; Persons, 1989). Depressed clients may
present with a variety of problems related to their nega-
tive moods. Depressed clients are more likely to benefit
from cognitive therapy when therapist and client agree
on the treatment goals and therapy tasks (Rector, Zuroff,
& Segal, 1999). When devising a treatment plan, thera-
pist and client can write a list of target problems to be ad-
dressed (Persons, 1989). The therapist should try to clar-
ify discrete problems in specific terms, understand the
relationships among the different problem areas, identify
core irrational beliefs related to the client's problems,
and set initial priorities for treatment (Persons, 1989).
Stage One of therapy includes several elements useful
for all depressed clients. The therapeutic alliance, assess-
ment, and diagnostic evaluation all lay the foundation for
effective therapy. These basic elements can be initiated
during the first therapy session. However, these issues
often remain relevant throughout the course of treat-
ment. By the end of Stage One, the therapist should be
able to document a preliminary treatment plan that is
comprehensive in scope yet adapted to each particular
client. Elements from Stage Two can be used to describe
the primary strategies that will be used to promote adap-
tive changes in the client.
Stage Two: Modules for Active Therapy
During the second stage of treatment, different com-
ponents are used for different clients. Because major de-
pression can be displayed in many different forms, differ-
ent clients often need different treatment components.
The various treatment modules provide adequate flexi-
bility for the therapist to confront depressive symptoms
as they are manifested in different clients reacting to dif-
ferent life circumstances (e.g., unemployment and finan-
cial stress versus chronic relationship difficulties versus
long-standing deficits in self-esteem). The therapist can
select the module(s) most directly related to the client's
symptoms. The time spent on each module will vary
Z34
d e p e n d i n g on the client's needs, insight, motivation,
a n d progress. Some issues can be a d d r e s s e d quickly a n d
progress may be seen after several sessions. For o t h e r cli-
ents, a particular topic may c o n f r o n t long-standing diffi-
culties that n e e d m o r e time before c h a n g e can be ex-
pected. Also, the framework allows a d e q u a t e r o o m in the
t r e a t m e n t plan for addressing c o m m o n c o m o r b i d dis-
orders, such as generalized anxiety disorder, alcohol
abuse, or d e p e n d e n t personality disorder.
Target Area: Reduced Activity
Many d e p r e s s e d clients can benefit from simple strate-
gies designed to help them b e c o m e m o r e active through-
o u t their day (Lejuez, H o p k o , LePage, H o p k o , & McNeil,
2001). T h e behavioral focus on activity provides a con-
crete a n d obset~'able starting p o i n t for change. Behav-
ioral activation strategies include guiding clients to mon-
itor their daily actMties, evaluating different activities t0r
the d e g r e e o f mastery a n d pleasure they p r o d u c e , a n d
assigning a variety of simple activities to be c o m p l e t e d be-
tween sessions. T h e goal is to increase the frequency of
pleasant a n d reinforcing actMties in the client's typical
day. Research has f o u n d that these behavioral strategies
can be very effective in h e l p i n g clients overcome their de-
pression (Gortnei; Gollan, Dobson, & Jacobson, 1998;
J a c o b s o n et al., 1996). F u r t h e r m o r e , activities c o m p l e t e d
between sessions can provide o p p o r t u n i t i e s for clients to
notice the cognitions related to their negative moods.
Target Area: Impaired Social Functioning
In therapy, it can be an easy transition from focusing
on increasing activity to increasing social activity. Behav-
ioral strategies designed to facilitate social activity can
provide a usefifl intervention early in therapy because
many clients have i n t e r p e r s o n a l p r o b l e m s that n e e d to be
addressed. T h e r a p y can help to (a) increase the fre-
quency of pleasant social activities in the client's typical
week, (b) improve basic social skills or assertiveness, (c)
r e d u c e tendencies tot social withdrawal when feeling de-
pressed, a n d (d) increase the a m o u n t of social s u p p o r t
a n d intimacy that is e x p e r i e n c e d by the client (Over-
holsm; 1995b). Also, interventions can focus on marital
conflict as it relates to depressive symptomatology (Beach
& O'Leary, 1992). F u r t h e r m o r e , most social activities can
elicit cognitive a n d e m o t i o n a l reactions that are relevant
to therapy. Clients can begin to identify a n d c o n f r o n t
negative cognitions that disrupt social functioning.
Target Area: Ineffective Coping With Recent Stressors
Many clients r e p o r t that their depression was trig-
g e r e d by a r e c e n t stressful life event. Negative life events
have b e e n f o u n d to p r e c e d e the onset of major depres-
sion (Fava, Munari, Pavan, & Kellner, 1981), a t t e m p t e d
suicide (DeVanna et al., 1990), and c o m p l e t e d suicide
Overholser
(Rich et al., 1991). HoweveL clients can learn to improve
their ability to cope with negative life events. T h e thera-
pist can help clients evaluate their r e c e n t c o p i n g strate-
gies a n d identify effective as well as ineffective c o p i n g
strategies (Overholser, 1996c). In addition, clients can
learn to evaluate the secondary p r o b l e m s (e.g., marital
discord) that have arisen from their ineffective c o p i n g ef-
tbrts. Clients can learn to r e d u c e their reliance on indi-
rect or avoidance c o p i n g strategies (e.g., alcohol abuse or
excessive food consumption) that have been used as mal-
adaptive attempts to elevate their mood. In most situa-
tions, it is best for the therapist to focus on generic coping
skills that transcend the specific p r o b l e m e n c o u n t e r e d by
the client. In addition, the therapist can e n c o u r a g e flexi-
bility a n d creatMty in the client's c o p i n g eftbrts. T h e r a p y
can help clients learn how to tolerate negative m o o d
states, express their emotions in constructive ways, a n d
use these negative e m o t i o n s as cues to stop, think, plan,
a n d review their coping options.
Target Area: Deficient Problem-Solving Skills
A central c o m p o n e n t of effective coping involves help-
ing clients to improve their i n t e r p e r s o n a l problem-solv-
ing abilities (Overholser, 1996a). Some d e p r e s s e d clients
lack a d e q u a t e skill in s o M n g i n t e r p e r s o n a l p r o b l e m s
(Gotlib & Asarnow, 1979). They may display a rigid ap-
proach to p r o b l e m s (Perrah & Wichman, 1987), a n d
tend to anticipate negative consequences from their at-
tempts to solve the p r o b l e m (Priester & Clum, 1993).
P r o b l e m - s o M n g therapy has b e e n shown to be an effec-
tive t r e a t m e n t for adults with major depression (Nezu,
1986). As a starting point, clients n e e d to develop an
adaptive attitude toward life problems, accepting prob-
lems as a natural part of life (Nezu, Nezu, & Perri, 1989).
Some clients n e e d to r e d u c e their t e n d e n c y to r e s p o n d
impulsively o r emotionally, a n d learn to think t h r o u g h
the situation until a reasonable solution is found. T h e
p r o b l e m should be d e f i n e d in terms of concrete goals
(D'Zurilla, 1986) that are b o t h specific a n d realistic,
often subdividing a c o m p l e x i n t e r p e r s o n a l p r o b l e m into
m a n a g e a b l e c o m p o n e n t s . T h e n , clients can be assisted in
g e n e r a t i n g a wide variety o f possible alternatives, b e i n g
creative a n d flexible d u r i n g this process. T h e m o r e altm:
natives that have been generated, the more likely it becomes
that the client can find aM adequate option (D'Zurilla &
Nezu, 1980). After a n u m b e r of possible solutions have
b e e n generated, the therapist can guide the discussion
t h r o u g h rational decision-making, exanfining the short-
term and long-term consequences that are e x p e c t e d to
follow the different plans. Clients may be asked to write a
list o f the anticipated advantages a n d disadvantages of
each option. T h e Socratic m e t h o d can be useful in guid-
ing the therapeutic dialogue when generating options or
evaluating their likely outcomes (Overholser, 1993b, 1993c,
 CBT of Depression
1994). Finally, therapist and client can devise and imple-
m e n t a specific coping plan and evaluate its effectiveness.
Target Area: Cognitive Biases
Cognitive schemas can guide the perception and in-
terpretation of stressful events (Schmidt, Schmidt, &
Young, 1999). Depressed patients tend to notice nega-
tive information while paying less attention to the posi-
tive events in their lives (Ingrain & Wisnicki, 1991). De-
pressed clients may r e s p o n d to m i n o r stressors as if
they were major traumas, displaying a pattern of over-
reaction to and magnification of negative events. Many
depressed clients display tendencies to view their life
events from a negative, pessimistic, and self-blaming per-
spective. Cognitive therapy often focuses on the cogni-
tive symptoms o f depression, especially helplessness,
hopelessness, and worthlessness. The negative beliefs
f o u n d in depression may b e c o m e activated by negative
m o o d states (Persons & Miranda, 1992). Negative emo-
tions provide information regarding the ways that cli-
ents ascribe personal m e a n i n g to life events (McGinn &
Young, 1996).
Cognitive therapy can be used to identify, confront,
challenge, and reduce depressive cognitions (A. T. Beck
et al., 1979; Overholser, 1995c). Therapy can help cli-
ents to identify and c o n f r o n t the recurrent themes that
guide the interpretation of events (McGinn & Young,
1996). Cognitive therapy has b e e n supported by exten-
sive research (Conte, Plutchik, Wild, & Karasu, 1986;
Elkin et al., 1989; Harpin, Liberman, Marks, Stern, &
g o h a n n o n , 1982; Thase, Simons, Cahalane, McGealy, &
Harden, 1991). The therapist can help a client learn to
identify and m o n i t o r his or her internal m o n o l o g u e and
begin to appreciate the relationships between thoughts,
emotions, and behaviors. Because the client's automatic
thoughts occur quickly and are not evaluated logically
(Wright & Beck, 1983), the client n e e d s to gain dis-
tance from this perspective. A simple self-monitoring
form, called the "Structured Diary," can guide clients
t h r o u g h the cognitive awareness process (Overholser,
1995c). Clients benefit from structure that helps t h e m
learn to recognize, record, and refute specific maladap-
tive cognitions.
Over the course of therapy, the client should develop
beliefs that are both positive and realistic. Even when cli-
ents have learned to shift their views, the adaptive changes
in attitudes often occur several days after a negative event
has occurred. It is useful for clients to shorten the tempo-
ral delay required to reduce negative cognitions (Over°
holser, 1995c). Finally, a useful goal for most clients in-
volves helping them to find positive qualities in negative
situations. This difficult task can help clients learn to ap-
preciate that some positive qualities exist even when con-
fronted with adversity.
135
Target Area: Negative View of Self
The negative cognitions that underlie depression
often focus on the self (Beutler et al., 2000). Low self-
esteem has been related to depression (A. T. Beck, Steer,
& Epstein, 1992; Ingham, Kreitman, Miller, Sashidharan,
& Suttees, 1986) and suicide risk (Overholser, Adams,
Lehnert, & Brinkman, 1995). Therapy can help de-
pressed clients e n h a n c e their feelings of self-esteem and
self-control (Overholser, 1996b). This aspect of therapy
usually begins with a general exploration of the client's
view of self. Assessment of self-esteem can be guided by
standardized questionnaires (e.g., Rosenberg Self-Esteem
Scale; Rosenberg, 1965) or a semistructured worksheet
(Overholser, 1993a).
It is helpful to explore the client's view of self from a
broad conceptualization instead of a narrow dichotomi-
zation of positive versus negative self-esteem (Segal,
1988). The exploration of the self-schema can provide
the therapist with a t h o r o u g h understanding of the cli-
ent's past events, present functioning, and goals for the
future. Depression is related to a narrow conceptualiza-
tion of the self with a heavy focus on a few central areas
(Linville, 1987), such as success at work or school, while
minimizing the importance of other areas of life. Thus,
disruption in one of these key areas can result in feelings
of despair or even hopelessness.
A negative view of self may be related to objectively
poor performance in areas of life that are important to
the client. Alternatively, a negative view of self may be re-
lated to subjective evaluations that are based on harsh
evaluation standards or unrealistically high goals. De-
pressed patients are likely to use inappropriate standards
of c o m p a r i s o n (Swallow & Kuiper, 1988) and tend to
focus on the ways they appear inferior to others (Swallow
& Kuiper, 1993). Both depression and low self-esteem are
related to a d e m a n d for approval and high expectations
for oneself (McClennan, 1987). A tendency for perfec-
tionistic standards can result in negative evaluations of
the self (Rehm, 1982). When aspirations are set too high,
average performance will appear inferior (Golin & Ter-
rell, 1977). The therapist can help clients identify specific
problem areas that can be changed versus other problem
areas that would benefit from revised goals and new eval-
uative standards. Also, the therapist can encourage cli-
ents to increase their use of self-reinforcement for posi-
tive acts or desirable qualities that are already present.
Other Issues Relevant to Stage Two
Sometimes, therapy needs to identify and confront
underlying predispositions for depression. W h e n the cli-
ent has not responded to treatment focused on current
biopsychosocial factors, it can be useful to explore tile
possible etiology of the depressive symptoms (Overholser,
1998a). Chronic or recurrent forms of depression may be
236 Overholser
related to e n d u r i n g vulnerabilities, sometimes related to
loss, neglect, or abuse suffered during childhood. Par-
ents who displayed harsh, critical, or rejecting attitudes
may have instilled these negative attitudes in the client
(A. T. Beck, 1987). Early maladaptive schemas may lay the
foundation for the distorted perception and interpreta-
tion of events (Young, Beck, & Weinberger, 1993), Also,
the therapist may identify long-standing tendencies for
introversion or interpersonal d e p e n d e n c y that are re-
lated to depression (Barnett & Gotlib, 1988). The ther-
apy dialogue may shift from recent precipitating events
to a discussion of remote predisposing factors and how
they can be managed in the present. Therapeutic discus-
sions of predisposing factors can be helpful in promoting
insight in the client. However, an exploration of develop-
mental antecedents does not easily stimulate change.
The active phase of therapy usually begins during the
second session, and often involves weekly therapy ses-
sions. Therapist and client negotiate one or two domains
that seem especially relevant to the client's depression.
After therapy has been u n d e r way and the client has
shown preliminary signs of improvement, some clients
may be able to continue with sessions provided every
other week. This scheduling will necessitate a motivated
client who complies with the behavioral activities con-
ducted between sessions. Stage Two ends when the client
has made noticeable reduction in both depressive symp-
toms and social/occupational impairment.
Stage Three: Relapse Prevention
Most clients with major depression can be treated suc-
cessfully. More than half of depressed patients recover
within 6 months, and 70% recover within 1 year (Keller et
al., 1992). Unfortunately, depression is an episodic dis-
order. Even after successful treatment, depressed patients
remain vulnerable to relapse or recurrence. The majority
(75%) of depressed patients experience another depressive
episode within 5 years after recovery (Maj, Veltro, Pirozzi,
Lobrace, & Magliano, 1992). There is some evidence to sug-
gest that depressive cognitions persist over time (Giles,
Etzel, & Biggs, 1989). Furthermore, depressed patients with
suicidal ideation may remain vulnerable to relapse for 6
to 12 months after their discharge from a psychiatric hos-
pital (Overholser, Miller, & Norman, 1987).
Fortunately, the risk of relapse can be reduced by pro-
viding t h o r o u g h treatment until the client has fully recov-
ered (Thase et al., 1992). Thus, therapy should not be too
brief, even if financial concerns may limit the n u m b e r of
sessions. A comprehensive treatment plan can help ensure
that clients will make reasonable progress. Also, cognitive
therapy has shown the potential for reducing the risk of
relapse (Evans et al., 1992). Patients treated with cogni-
tive therapy (with or without antidepressant medications)
showed significantly lower rates of relapse than patients
treated with medications alone (Evans et al.). Cognitive-
behavioral therapy can also help reduce the residual symp-
toms of depression that remain after pharmacological
treatment (Fava et al., 1994; Pava, Fava, & Levenson, 1994).
As part of relapse prevention, the therapist should
conduct an ongoing evaluation of depressive symptoms.
This evaluation typically involves the use of brief ques-
tionnaires to track the severity of depressive symptoms
over time. Clients can be forewarned that depression is
an episodic disorder, and a resurgence of depressive
symptoms is likely to occur. However, if forewarned and
prepared, clients may be able to identify their own pro-
dromal pattern of depressive symptoms and learn to seek
treatment promptly. Prompt reinitiation of therapy can
reduce the duration of the new depressive symptoms
(Kupfer, Frank, & Perel, 1989).
After clients have made adequate progress and before
therapy is terminated, the therapist can help to identify
risk factors that could trigger a relapse (OverholseI,
1998b). These risk factors may involve situational triggers
(e.g., interpersonal conflict or loss) or other factors (e.g.,
recent discontinuation of medications, comorbid diagno-
sis of dysthymia) that increase the risk of relapse. Also,
after recovery, even mild feelings of depression may be ca-
pable of reactivating depressive cognitions and trigger a re-
lapse (Teasdale, Segal, & Williams, 1995). After the client's
risk factors have been identified, the client can learn to
prepare for a temporary lapse in mood. It can be helpful
for recovered clients to use negative emotional states as
cues that remind them to activate the coping skills they de-
veloped earlier in therapy. Also, clients may be able to view
a temporary lapse in functioning as an important opportu-
nit'/to learn about their own strengths, weaknesses, and
vulnerabilities that still exist despite effective therapy.
Therapy can be most helpful when clients learn general
coping strategies that can be applied over time and across
situations (Hollon, DeRubeis, & Seligman, 1992). How-
ever, sometimes, clients can anticipate specific challenges
that are likely to be encountered in the near future (e.g.,
visiting the in-laws over the holidays). Therapist and client
may be able to work together to develop specific coping
strategies relevant to these high-risk situations. Therapy
can enhance the client's awareness of freedom and choice
in order to reduce automatic, habitual, and maladaptive
patterns of responding to events (Teasdale et al., 2000).
Cognitive changes play an important role in relapse
prevention (Persons, 1993). Clients need to learn that
negative thoughts represent one view of the situation
(Teasdale et al., 2002), and this particular view may not
be the most accurate or the most helpful. By anticipating
u p c o m i n g events, the client may be able to approach a
difficult situation with confidence and a sense of humor.
The therapist may even use role-played interactions to
help clients practice new coping skills and learn to tolerate
negative emotions, especially sadness, anger, and frnstra-
 CBT of Depression
tion. It is usually easier to control the r e t u r n o f d e p r e s s e d
thoughts a n d feelings while they are still mild (Teasdale
et al., 1995). It can be i m p o r t a n t to c o n f r o n t a n d chal-
lenge the client's perfectionistic standards so that m i n o r
negative reactions do n o t escalate into despair a n d hope-
lessness (Ludgate, 1995).
As the e n d of therapy approaches, the therapist can ask
clients to record their experiences in therapy. This can be
framed in terms of a serf-help guidebook, written by the cli-
ent and saved for the client's personal use in case the symp-
toms return at a later date. The writing should emphasize
the positive gains that were made over the course of therapy.
By successfully confronting difficult situations, clients ac-
quire specific memories of their ability to cope effectively
(Teasdale et al., 1995). Clients can record several specific
strategies that were found useful in overcoming their de-
pressive tendencies.
D u r i n g Stage Three, the frequency o f therapy is re-
d u c e d a n d eventually discontinued. T h e therapist can
c o n t i n u e to provide m a i n t e n a n c e therapy as n e e d e d , a n d
should remain available over time for occasional booster
sessions or telephone contacts. T h e longer depressed cli-
ents r e m a i n nondepressed, the lower their risk of relapse
(Maj et al., 1992). T h e issues that are addressed d u r i n g
the relapse prevention stage o f t r e a t m e n t are relevant to
all d e p r e s s e d clients. Even clients who are treated with
antidepressant m e d i c a t i o n s can benefit from some o f the
material that is covered as part of relapse prevention.
Conclusions
Cognitive-behavioral t r e a t m e n t o f depression provides
a b r o a d m o d e l for therapists. T h e m o d e l can be simpli-
fied through the use of three stages to guide the treatment
plan. Core issues that are relevant to all clients are ad-
dressed d u r i n g Stage O n e a n d Stage Three. D u r i n g Stage
Two, different issues are addressed for different clients.
D u r i n g Stage One, the therapist works to establish a
s o u n d t h e r a p e u t i c alliance. In addition, all clients un-
d e r g o a similar assessment a n d diagnostic evaluation in
o r d e r to begin developing a c o m p r e h e n s i v e t r e a t m e n t
plan. Clients are evaluated in terms o f specific facets of
their depression that m i g h t n e e d to be addressed in treat-
ment. Stage O n e addresses issues that are relevant to all
clients, even those who are r e f e r r e d for antidepressant
medications, w h e t h e r used alone or in c o m b i n a t i o n with
psychotherapy. F u r t h e r m o r e , therapeutic relationship is-
sues a n d the assessment o f depressive symptoms should
be an o n g o i n g p a r t o f therapy with all clients.
D u r i n g Stage Two, the therapist is able to customize
the t r e a t m e n t plan to fit the u n i q u e needs o f each client
while r e m a i n i n g consistent with empirical research on
the t r e a t m e n t o f depression. A series o f m o d u l e s can be
used to allow m a x i m u m flexibility within sessions while
m a i n t a i n i n g a logical focus across sessions. Several issues
237
may be addressed within a single session, b u t in a m a n n e r
that reduces r a n d o m topic j u m p i n g a n d allows for a sys-
tematic progression across sessions. Thus, clients can bring
assorted issues to be discussed in session (e.g., a b o r i n g
w e e k e n d at h o m e watching television alone, r e c e n t con-
flict with spouse) a n d the therapist can choose a treat-
m e n t m o d u l e relevant to the client's needs (e.g., increas-
ing social activity, improving problem-solving skills). T h e
t r e a t m e n t plan can provide clear goals a n d specific strat-
egies to guide each session,
During Stage Three, all depressed clients are encouraged
to address issues surrounding the maintenance of therapeu-
tic gains. Relapse prevention guidelines can be helpful for
most clients, regardless of the nature or duration of therapy
that has been provided. Issues pertaining to relapse preven-
tion do not n e e d to wait until the final few sessions. Instead,
the seeds for long-term maintenance should be planted
early in therapy, shortly after the clients have begun to show
progress in reducing their depressive symptoms.
Therapists must strive for a balance when devising
their treatment plans. It would be inefficient to treat each
client as unique, a n d it would be unproductive to treat
each client as identical. The integrative three-stage m o d e l
provides structure while allowing flexibility in the treat,
m e n t plan. T h e p r o p o s e d m o d e l balances i d i o g r a p h i c
a n d n o m o t h e t i c a p p r o a c h e s to treatment. Also, the pro-
posed t r e a t m e n t m o d e l provides a useful training format
for therapists who are l e a r n i n g the cognitive-behavioral
a p p r o a c h to the t r e a t m e n t o f depression o r providing
therapy in a g r o u p format. Future research may be able
to e x a m i n e the utility o f this c o m p r e h e n s i v e model. Also,
the p r o p o s e d framework may be e x p a n d e d to a d d m o d -
ules to address specific needs o f different clients (e.g., de-
pression m i x e d with marital discord, d e p r e s s i o n in medi-
cal settings, depression in adolescence vs. old age).
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I thank Tony"Spirito, Eric Youngstrom,Julia DiFilippo, Eden Silverman,
Julie Exline, Zee Butt, and Tim DeJong for comments on earlier drafts
of this manuscript.
Address correspondence to James c. Overholser, Ph.D.. Department
of Psychology, Case Western Reserve University, 10900 Euclid Avenue.
Cleveland, OH 44106-7123; e-mail: jxo5@po.cwru.edu.
Received: January 19. 2002
Accepted: July 24, 2002