Cognitive Therapy of Depression and Suicide*

A. J O H N R U S H , M.D.t Oklahoma City, Okla.

A A R O N T . BECK, M.D.i Philadelphia, Pa.

This article reviews the cognitive therapy of depression. The psychotherapy

based on this theory consists of behavioral and verbal techniques to change
cognitions, beliefs, and errors in logic in the patient's thinking. A few of the
various techniques are described and a case example is provided. Finally, the
outcome studies testing the efficacy of this approach are reviewed.

INTRODUCTION
Beck r e f o r m u l a t e d the p h e n o m e n o n o f depression f r o m a cognitive
1

viewpoint. T h i s f o r m u l a t i o n was d e s i g n e d t o p r o v i d e a m o d e l f o r
u n d e r s t a n d i n g t h e r e l a t i o n s h i p s o f t h e signs a n d s y m p t o m s o f t h e
depressive s y n d r o m e (e.g., g u i l t , d i f f i c u l t y c o n c e n t r a t i n g , l o w e n e r g y ,
etc.). I n a d d i t i o n , t h e c o g n i t i v e f r a m e w o r k was t o p r o v i d e a basis f o r a
systematic p s y c h o t h e r a p y o f d e p r e s s i o n c a l l e d " c o g n i t i v e t h e r a p y . "
T h i s paper will review briefly the cognitive theory o f depression.
W e w i l l describe a f e w specific p s y c h o t h e r a p y t e c h n i q u e s u s e d i n t h e
c o g n i t i v e t h e r a p y o f d e p r e s s i o n t o c h a n g e c o g n i t i o n s . A case e x a m p l e
will illustrate the application o f cognitive therapy. Finally, we will
r e v i e w t h e c o n t r o l l e d p s y c h o t h e r a p y r e s e a r c h studies d e s i g n e d t o test
the efficacy o f c o g n i t i v e t h e r a p y w i t h d e p r e s s e d p a t i e n t s .

THE COGNITIVE THEORY OF DEPRESSION

T h e c o g n i t i v e t h e o r y o f d e p r e s s i o n is a f o r m u l a t i o n w h i c h g r e w o u t
o f careful clinical observation a n d experimental testing. T h i s interplay
o f a c l i n i c a l a n d e x p e r i m e n t a l a p p r o a c h has a l l o w e d f o r c a r e f u l e v o l u -
t i o n o f this m o d e l a n d o f t h e p s y c h o t h e r a p y i t has s p a w n e d . 2

T h e c o g n i t i v e m o d e l postulates t h r e e specific n o t i o n s t o e x p l a i n
d e p r e s s i o n : c o g n i t i v e t r i a d , schemas, a n d c o g n i t i v e e r r o r s . T h e c o g n i -
tive t r i a d consists o f t h r e e m a j o r c o g n i t i v e p a t t e r n s t h a t i n d u c e t h e
patient t o r e g a r d himself, his f u t u r e , a n d his experiences i n a n i d i o s y n -
cratic m a n n e r .

* P r e s e n t e d at t h e T h i r t e e n t h N a t i o n a l Scientific M e e t i n g o f t h e A s s o c i a t i o n f o r t h e A d -
v a n c e m e n t o f P s y c h o t h e r a p y , M a y 1, 1 9 7 7 , T o r o n t o , C a n a d a .
tAssistant Professor, D e p a r t m e n t o f Psychiatry a n d Behavioral Sciences, University o f
O k l a h o m a . Mailing address: U n i v e r s i t y o f O k l a h o m a , D e p t . o f P s y c h i a t r y a n d B e h a v i o r a l
Sciences, P . O . B o x 26901, O k l a h o m a City, O k l a . 73190.
^Professor, Department o f Psychiatry, University o f Pennsylvania, Philadelphia, P e n n -
sylvania 19104.

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202 A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

Cognitive Triad
T h e first c o m p o n e n t o f t h e t r i a d revolves a r o u n d t h e p a t i e n t ' s n e g a -
tive v i e w o f h i m s e l f . H e sees h i m s e l f as d e f e c t i v e , i n a d e q u a t e , o r u n -
w o r t h y . H e t e n d s t o a t t r i b u t e his u n p l e a s a n t e x p e r i e n c e s t o a p h y s i c a l ,
m e n t a l , o r m o r a l d e f e c t i n h i m s e l f . T h e p a t i e n t believes h e is u n d e s i r -
able a n d w o r t h l e s s because o f his p r e s u m e d defects. H e tends to
u n d e r e s t i m a t e o r c r i t i c i z e h i m s e l f because o f t h e m . F i n a l l y , h e believes
h e lacks t h e a t t r i b u t e s h e t h i n k s a r e essential t o a t t a i n h a p p i n e s s a n d
contentment.
T h e s e c o n d c o m p o n e n t consists o f t h e d e p r e s s e d person's t e n d e n c y
t o i n t e r p r e t his o n g o i n g e x p e r i e n c e s i n a n e g a t i v e w a y . H e sees t h e
w o r l d as m a k i n g e x o r b i t a n t d e m a n d s o n h i m a n d / o r p r e s e n t i n g i n s u -
p e r a b l e obstacles t o r e a c h i n g his l i f e goals. H e m i s i n t e r p r e t s his i n t e r a c -
t i o n s w i t h t h e w o r l d a r o u n d h i m as e v i d e n c e f o r d e f e a t o r d e p r i v a t i o n .
T h e s e n e g a t i v e m i s i n t e r p r e t a t i o n s a r e e v i d e n t by o b s e r v i n g t h a t t h e
p a t i e n t n e g a t i v e l y c o n s t r u e s s i t u a t i o n s even w h e n less n e g a t i v e , m o r e
plausible, alternative i n t e r p r e t a t i o n s are available. T h e depressed
p e r s o n m a y realize t h a t his i n i t i a l n e g a t i v e i n t e r p r e t a t i o n s a r e biased i f
he is p e r s u a d e d t o r e f l e c t o n these less n e g a t i v e a l t e r n a t i v e e x p l a n a t i o n s .
I n t h i s w a y , he can c o m e t o realize t h a t h e t a i l o r e d t h e facts t o f i t his
preconceived negative conclusions.
T h e t h i r d c o m p o n e n t consists o f a n e g a t i v e v i e w o f t h e f u t u r e . A s
t h e d e p r e s s e d p e r s o n l o o k s a h e a d , he a n t i c i p a t e s t h a t his c u r r e n t
d i f f i c u l t i e s o r s u f f e r i n g w i l l c o n t i n u e i n d e f i n i t e l y . H e expects u n r e m i t -
t i n g h a r d s h i p , f r u s t r a t i o n , a n d d e p r i v a t i o n . W h e n he t h i n k s o f u n -
d e r t a k i n g a specific task, he expects t o f a i l .
T h e c o g n i t i v e t h e o r y c o n s i d e r s t h e o t h e r signs a n d s y m p t o m s o f t h e
depressive s y n d r o m e t o be consequences o f t h e a c t i v a t i o n o f t h e n e g a t i v e
c o g n i t i v e p a t t e r n s . F o r e x a m p l e , i f t h e p a t i e n t i n c o r r e c t l y thinks he is
b e i n g r e j e c t e d , he w i l l r e a c t w i t h t h e same n e g a t i v e a f f e c t (e.g., sadness,
a n g e r ) t h a t occurs w i t h actual r e j e c t i o n . I f he e r r o n e o u s l y believes h e is
a social o u t c a s t , he w i l l f e e l l o n e l y .
T h e m o t i v a t i o n a l s y m p t o m s (e.g., paralysis o f w i l l , escape a n d a v o i -
d a n c e wishes, etc.) c a n be e x p l a i n e d as consequences o f n e g a t i v e c o n d i -
t i o n s . "Paralysis o f w i l l " r e s u l t s f r o m t h e p a t i e n t ' s p e s s i m i s m a n d h o p e -
lessness. I f he expects a n e g a t i v e o u t c o m e , h e w o n ' t c o m m i t h i m s e l f t o a
g o a l o r u n d e r t a k i n g . S u i c i d a l wishes c a n be u n d e r s t o o d as a n e x t r e m e
e x p r e s s i o n o f t h e d e s i r e t o escape f r o m w h a t appears t o be i n s o l v a b l e
p r o b l e m s o r a n u n b e a r a b l e s i t u a t i o n . T h e d e p r e s s e d p e r s o n m a y see
h i m s e l f as a w o r t h l e s s b u r d e n a n d c o n s e q u e n t l y believe t h a t e v e r y o n e ,
h i m s e l f i n c l u d e d , w i l l be b e t t e r o f f w h e n h e is d e a d .
I n c r e a s e d d e p e n d e n c y is also e x p l i c a b l e i n c o g n i t i v e t e r m s . Because
h e sees h i m s e l f as i n e p t a n d u n d e s i r a b l e , t h e d e p r e s s e d p e r s o n u n r e a l i s -
C O G N I T I V E T H E R A P Y OF D E P R E S S I O N AND S U I C I D E 203

tically o v e r e s t i m a t e s t h e d i f f i c u l t y o f n o r m a l tasks a n d expects t h i n g s t o

t u r n p u t b a d l y . T h e p a t i e n t t e n d s t o seek h e l p a n d r e a s s u r a n c e f r o m
o t h e r s w h o m he c o n s i d e r s m o r e c o m p e t e n t a n d c a p a b l e .
F i n a l l y , t h e c o g n i t i v e m o d e l m a y also e x p l a i n t h e p h y s i c a l s y m p t o m s .
A p a t h y a n d l o w e n e r g y m a y r e s u l t f r o m t h e p a t i e n t ' s b e l i e f t h a t he is
d o o m e d t o f a i l u r e i n a l l his e f f o r t s . A n e g a t i v e view o f t h e f u t u r e (a
sense o f f u t i l i t y ) m a y l e a d to " p s y c h o m o t o r i n h i b i t i o n . "

Schemas
A s e c o n d m a j o r i n g r e d i e n t i n t h e c o g n i t i v e m o d e l consists o f t h e n o -
t i o n o f schemas. T h i s n o t i o n is u s e d t o e x p l a i n w h y a d e p r e s s e d p a t i e n t
clings t o p a i n f u l a t t i t u d e s d e s p i t e o b j e c t i v e e v i d e n c e o f p o s i t i v e factors i n
his l i f e .
A n y s i t u a t i o n is c o m p o s e d o f a p l e t h o r a o f s t i m u l i . A n i n d i v i d u a l se-
lectively a t t e n d s t o specific s t i m u l i , c o m b i n e s t h e m i n a p a t t e r n a n d c o n -
ceptualizes t h e s i t u a t i o n . A l t h o u g h d i f f e r e n t p e r s o n s m a y c o n c e p t u a l i z e
t h e same s i t u a t i o n i n d i f f e r e n t ways, a p a r t i c u l a r p e r s o n t e n d s t o be
consistent i n his responses t o s i m i l a r types o f events. R e l a t i v e l y stable
c o g n i t i v e p a t t e r n s f o r m t h e basis f o r t h e r e g u l a r i t y o f i n t e r p r e t a t i o n s o f
a p a r t i c u l a r set o f s i t u a t i o n s .
T h e t e r m " s c h e m a " designates these stable c o g n i t i v e p a t t e r n s .
W h e n a p e r s o n faces a p a r t i c u l a r c i r c u m s t a n c e , a s c h e m a r e l a t e d t o t h e
c i r c u m s t a n c e is a c t i v a t e d . T h e s c h e m a is t h e basis f o r m o l d i n g d a t a i n t o
c o g n i t i o n s ( d e f i n e d as a n y m e n t a l a c t i v i t y w i t h v e r b a l c o n t e n t ) . T h u s , a
s c h e m a constitutes t h e basis f o r s c r e e n i n g o u t , d i f f e r e n t i a t i n g , a n d c o d -
i n g t h e s t i m u l i t h a t c o n f r o n t t h e i n d i v i d u a l . H e categorizes a n d
evaluates his e x p e r i e n c e s t h r o u g h a m a t r i x o f schemas.
T h e k i n d s o f schemas e m p l o y e d d e t e r m i n e h o w a n i n d i v i d u a l w i l l
s t r u c t u r e d i f f e r e n t e x p e r i e n c e s . A s c h e m a m a y be i n a c t i v e at o n e t i m e
b u t can be a c t i v a t e d by specific e n v i r o n m e n t a l i n p u t s . T h e schemas ac-
t i v a t e d i n a specific s i t u a t i o n d i r e c t l y d e t e r m i n e h o w t h e p e r s o n a f f e c -
tively responds to the circumstance. F o r e x a m p l e , i f a p e r s o n is
c o n c e r n e d o v e r w h e t h e r o r n o t he is c o m p e t e n t a n d a d e q u a t e , he m a y be
assuming the validity o f the schema, "Unless I do e v e r y t h i n g perfectly,
I ' m a f a i l u r e . " I n t h i s case, he w i l l be c o n s t r u i n g s i t u a t i o n s i n t e r m s o f
t h e q u e s t i o n o f a d e q u a c y e v e n w h e n t h e q u e s t i o n is not r e l a t e d t o t h e
s i t u a t i o n . F o r i n s t a n c e , w h i l e s w i m m i n g at t h e beach (an a p p a r e n t l y f u n
a c t i v i t y not r e l a t e d t o p e r s o n a l c o m p e t e n c e ) , t h i s p e r s o n m a y be t h i n k i n g ,
" I s m y s w i m m i n g g o o d e n o u g h ? D o I l o o k as g o o d as t h e o t h e r s ? , " a n d
so f o r t h .
T h u s , t h e d e p r e s s e d p a t i e n t ' s c o n c e p t u a l i z a t i o n s o f specific s i t u a t i o n s
are d i s t o r t e d t o fit t h e schemas. T h e o r d e r l y m a t c h i n g o f s t i m u l u s a n d
a p p r o p r i a t e s c h e m a is u p s e t by t h e i n t r u s i o n o f o v e r l y active i d i o s y n -
204 A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y .

cratic schemas w h i c h displace m o r e a p p r o p r i a t e ones. As these i d i o s y n -

cratic schemas b e c o m e m o r e active, t h e y are e v o k e d by a w i d e r r a n g e o f
s t i m u l i w h i c h are less l o g i c a l l y r e l a t e d t o t h e m . T h e p a t i e n t loses c o n -
t r o l o f his t h i n k i n g processes a n d is u n a b l e t o i n v o k e o t h e r m o r e a p p r o -
p r i a t e schemas.
I n m i l d e r d e p r e s s i o n s t h e p a t i e n t is able t o v i e w his n e g a t i v e
t h o u g h t s w i t h some o b j e c t i v i t y . As t h e d e p r e s s i o n w o r s e n s , his t h i n k i n g
is i n c r e a s i n g l y d o m i n a t e d by n e g a t i v e ideas, a l t h o u g h t h e r e m a y be n o
logical connection between actual situations a n d negative i n t e r p r e t a -
t i o n s . T h e p a t i e n t is less able t o e n t e r t a i n t h e n o t i o n t h a t his n e g a t i v e
i n t e r p r e t a t i o n s are e r r o n e o u s , possibly because t h e s t r o n g e r i d i o s y n -
cratic schemas i n t e r f e r e w i t h r e a l i t y t e s t i n g a n d r e a s o n i n g . These
h y p e r v a l e n t schemas l e a d t o d i s t o r t i o n s o f r e a l i t y a n d c o n s e q u e n t l y t o
systematic e r r o r s i n t h e d e p r e s s e d person's t h i n k i n g .

Cognitive Errors
T h e s e systematic e r r o r s i n t h e logic o f t h e d e p r e s s e d p e r s o n ' s t h i n k -
i n g i n c l u d e a r b i t r a r y i n f e r e n c e , selective a b s t r a c t i o n , o v e r g e n e r a l i z a t i o n ,
magnification or minimization and personalization.
1. Arbitrary inference r e f e r s t o t h e process o f d r a w i n g a c o n c l u s i o n i n
t h e absence o f e v i d e n c e t o s u p p o r t t h e c o n c l u s i o n o r w h e n t h e e v i d e n c e
is c o n t r a r y t o t h e c o n c l u s i o n .
2. Selective abstraction consists o f f o c u s i n g o n a d e t a i l t a k e n o u t o f
c o n t e x t , i g n o r i n g o t h e r m o r e salient f e a t u r e s o f t h e s i t u a t i o n , a n d c o n -
c e p t u a l i z i n g t h e w h o l e e x p e r i e n c e o n t h e basis o f t h i s e l e m e n t .
3. Overgeneralization r e f e r s t o t h e p a t t e r n o f d r a w i n g a g e n e r a l c o n -
c l u s i o n o n t h e basis o f a single i n c i d e n t .
4. Magnification and minimization is r e f l e c t e d i n e r r o r s i n e v a l u a t i o n
t h a t a r e so gross as t o c o n s t i t u t e a d i s t o r t i o n .
5. Personalization r e f e r s t o t h e p a t i e n t ' s p r o c l i v i t y t o r e l a t e e x t e r n a l
events t o h i m s e l f w h e n t h e r e is n o basis f o r m a k i n g s u c h a c o n n e c t i o n .
T h e cognitive theory offers a hypothesis about f o r m i n g a predisposi-
tion to depression. B r i e f l y , t h e n o t i o n is t h a t e a r l y e x p e r i e n c e s
c o n s t i t u t e a basis f o r f o r m i n g a n e g a t i v e view a b o u t one's self, t h e f u t u r e ,
a n d the w o r l d a r o u n d . These negative concepts are f o r m u l a t e d i n
t e r m s o f schemas. Schemas m a y be l a t e n t b u t t h e y can be a c t i v a t e d by
specific c i r c u m s t a n c e s w h i c h a r e a n a l o g o u s t o e x p e r i e n c e s i n i t i a l l y
responsible f o r e m b e d d i n g the negative a t t i t u d e .
F o r e x a m p l e , d i s r u p t i o n o f a m a r i t a l s i t u a t i o n m a y activate t h e c o n -
cept o f i r r e v e r s i b l e loss associated w i t h d e a t h o f a p a r e n t i n c h i l d h o o d .
A l t e r n a t i v e l y , d e p r e s s i o n m a y be t r i g g e r e d b y a p h y s i c a l a b n o r m a l i t y o r
disease t h a t activates t h e n o t i o n h e is d e s t i n e d f o r a l i f e o f s u f f e r i n g .
W h i l e these a n d o t h e r events m i g h t be p a i n f u l t o m o s t p e o p l e , t h e y
C O G N I T I V E T H E R A P Y OF D E P R E S S I O N AND S U I C I D E 205

w o u l d n ' t necessarily p r o d u c e a d e p r e s s i o n unless t h e p e r s o n is p a r t i c u -

l a r l y sensitive t o t h e s i t u a t i o n because o f p r e v i o u s e x p e r i e n c e a n d c o n -
sequent predepressive cognitive o r g a n i z a t i o n .
I n response t o s u c h t r a u m a s t h e average p e r s o n w i l l still m a i n t a i n
i n t e r e s t i n a n d realistically a p p r a i s e o t h e r n o n t r a u m a t i c aspects o f his
life. H o w e v e r , t h e t h i n k i n g o f t h e d e p r e s s i o n - p r o n e p e r s o n becomes
m a r k e d l y c o n s t r i c t e d a n d n e g a t i v e ideas d e v e l o p a b o u t e v e r y aspect o f
his l i f e .
T h e r e is s u b s t a n t i a l e m p i r i c a l s u p p o r t f o r t h e c o g n i t i v e t h e o r y o f
depression. Naturalistic studies, clinical observations a n d e x p e r i m e n t a l
studies have r e c e n t l y b e e n r e v i e w e d . 2
Studies have d o c u m e n t e d t h e
presence a n d i n t e r c o r r e l a t i o n o f the constituents o f the "cognitive t r i a d "
i n association w i t h d e p r e s s i o n . Several studies d o c u m e n t t h e p r e s e n c e
o f specific c o g n i t i v e deficits (e.g., i m p a i r e d abstract r e a s o n i n g , selective
attention) i n depressed o r suicidal persons. 3
T h e presence o f dysfunc-
t i o n a l a t t i t u d e o r schemas has r e c e n t l y b e e n f o u n d w i t h d e p r e s s e d
patients. 4
H o w e v e r , m o r e e x p e r i m e n t a l s u p p o r t is n e e d e d . This
t h e o r y has l e d to a specific p s y c h o t h e r a p y for' d e p r e s s e d , s u i c i d a l
patients.

O V E R V I E W OF T H E T E C H N I Q U E S OF C O G N I T I V E T H E R A P Y
T h e c o g n i t i v e t h e o r y f o r m s t h e basis f o r " c o g n i t i v e t h e r a p y . " T h i s
t h e r a p y consists o f a n u m b e r o f specific t e c h n i q u e s f o r t r e a t i n g
d e p r e s s e d p a t i e n t s . T h e s e t e c h n i q u e s have b e e n c o m p i l e d i n a T r e a t -
ment Manual. 4
T h i s section w i l l r e v i e w a f e w o f these t e c h n i q u e s t o
p r o v i d e a f l a v o r f o r h o w this t r e a t m e n t is c o n d u c t e d . T h e n a n i l l u s t r a -
t i v e case e x a m p l e f o l l o w s .
C o g n i t i v e t h e r a p y is a s h o r t - t e r m , t i m e - l i m i t e d p s y c h o t h e r a p y
u s u a l l y i n v o l v i n g a m a x i m u m o f t w e n t y sessions o v e r t e n t o t w e l v e
weeks. T h e t h e r a p i s t actively d i r e c t s t h e discussion t o f o c u s o n selected
p r o b l e m areas p r e s e n t e d by t h e p a t i e n t . Q u e s t i o n i n g is f r e q u e n t l y u s e d
t o elicit specific t h o u g h t s , i m a g e s , d e f i n i t i o n s , a n d m e a n i n g s . For
e x a m p l e , t h e t h e r a p i s t m i g h t say, " W h a t was i t a b o u t t h e t e l e p h o n e call
w h i c h m a d e y o u m o s t u p s e t ? " " W h a t d i d t h e p h o n e call m e a n t o y o u ? , "
o r " W h a t w e r e y o u t h i n k i n g j u s t as y o u h u n g u p t h e t e l e p h o n e ? " I n a d -
d i t i o n , q u e s t i o n i n g is u s e d t o e x p o s e i n n e r c o n t r a d i c t i o n s , i n c o n s i s -
tencies, a n d flaws i n logic o f t h e p a t i e n t ' s t h i n k i n g o r c o n c l u s i o n s . Skill
a n d tact a r e r e q u i r e d , h o w e v e r , t o assure t h a t this q u e s t i o n i n g is n o t
c o n s t r u e d as a n i n t e r r o g a t i o n o r c r o s s - e x a m i n a t i o n , w h i c h m i g h t l e a d
t h e d e p r e s s e d p e r s o n t o c o n c l u d e t h a t his r e a s o n i n g p o w e r s a r e d e f e c -
tive.
T h e t h e r a p i s t a n d p a t i e n t c o l l a b o r a t e t o use a n e m p i r i c a l m e -
t h o d o l o g y t o focus o n specific p r o b l e m areas. T h e therapist must
206 A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

c l e a r l y u n d e r s t a n d t h e p a t i e n t ' s co n c e r i t u a l i z a t i o n s o f h i m s e l f a n d t h e
w o r l d a r o u n d h i m . I n essence, he m u s t be able to see t h e w o r l d
" t h r o u g h t h e p a t i e n t ' s eyes." I f t h e p a t i e n t ' s c o n c e p t u a l i z a t i o n s d i f f e r
f r o m t h e t h e r a p i s t ' s views o f r e a l i t y , the c o l l a b o r a t o r s t e n d t o r e c o n c i l e
the differences w i t h a logical e m p i r i c a l approach.
I n essence, t h e p a t i e n t ' s t h o u g h t are t r e a t e d as i f t h e y w e r e
hypotheses r e q u i r i n g v a l i d a t i o n , D u r i i k g this v a l i d a t i o n process ( o f t e n
c o n d u c t e d as h o m e w o r k ) , t h e p a t i e n t needs t o c l e a r l y u n d e r s t a n d w h a t
beliefs o r ideas (hypotheses) a r e b e i n g t e s t e d a n d , t h e r e f o r e , m u s t
u n d e r s t a n d t h e p u r p o s e o f each h o m e i v o r k a s s i g n m e n t . T e c h n i c a l l y ,
c o g n i t i v e t h e r a p y m a y be c o m p a r e d a scientific i n v e s t i g a t i o n : (1)
c o l l e c t i n g d a t a t h a t are as r e l i a b l e a n d v a l i d as possible; (2) f o r m u l a t i n g
hypotheses based o n t h e d a t a ; a n d (3) t e s t i n g a n d , i f i n d i c a t e d , r e v i s i n g
hypotheses based o n n e w i n f o r m a t i o n .
T h e d a t a consist o f t h e p a t i e n t ' s ";a u t o m a t i c t h o u g h t s , " f e e l i n g s , a n d
wishes. 5
T h e s e a u t o m a t i c t h o u g h t s o r c o g n i t i o n s a r e c o l l e c t e d as o r a l o r
w r i t t e n r e p o r t s f r o m t h e p a t i e n t . T h e t h e r a p i s t accepts these c o g n i t i o n s
as t r u t h f u l ( a l t h o u g h n o t necessarily accurate) r e p r e s e n t a t i o n s o f r e a l i t y ,
since t h e basic p r e m i s e o f t h e c o g n i t i v e t h e o r y is t h a t t h e d e p r e s s e d
p e r s o n n e g a t i v e l y m i s c o n s t r u e s his expediences.
F i r s t , t h e t h e r a p i s t tries t o elicit a u t o m a t i c t h o u g h t s s u r r o u n d i n g
each u p s e t t i n g e v e n t . H e tries t o o b t a i n specific e v i d e n c e f o r o r against
t h e p a t i e n t ' s p o t e n t i a l l y d i s t o r t e d o r dys :Fi i n c t i o n a l t h i n k i n g b y q u e s t i o n -
i n g the patient about the total circumstances o f a particular event,
Secondly, the cognitive therapist helps the patient to i d e n t i f y o r
i n f e r the assumptions o r themes i n the r e c u r r e n t negative automatic
t h o u g h t s . F o r e x a m p l e , s u c h a t h e m e m i g h t be " e x p e c t i n g t o f a i l " o r
" r e a d i n g rejection into personal situations T h e therapist helps the
p a t i e n t t o see t h a t such a b e l i e f m a y n o t necessarily r e f l e c t r e a l i t y . F o r
e x a m p l e , t h e t h e r a p i s t w o u l d use l o g i c , p e r s u a s i o n , a n d e v i d e n c e f r o m
t h e p a t i e n t ' s c u r r e n t a n d past f u n c t i o n i n g to get t h e p a t i e n t t o v i e w a
b e l i e f (e.g., " I a m u n a b l e t o l e a r n " ) as an i d e a o r h y p o t h e s i s r e q u i r i n g
v a l i d a t i o n r a t h e r t h a n as a b e l i e f .
T h i r d l y , t h e c o g n i t i v e t h e r a p i s t teachjes t h e p a t i e n t t o i d e n t i f y specific
e r r o r s o f logic i n his t h i n k i n g (e.g., a r b i t r a r y i n f e r e n c e , o v e r g e n e r a l i z a -
t i o n , etc.). L e a r n i n g t o r e c o g n i z e a n d c o r r e c t these e r r o r s h e l p s t h e
p a t i e n t t o r e p e a t e d l y assess t h e d e g r e e t o w h i c h his t h i n k i n g m i r r o r s
reality.
T h e p a t i e n t a n d t h e r a p i s t c o l l a b o r a t e t o i d e n t i f y basic a t t i t u d e s ,
b e l i e f s , a n d a s s u m p t i o n s , w h i c h ( a c c o r d i n g t o t h e m o d e l ) shape m o m e n t -
t o - m o m e n t t h i n k i n g . S o m e t i m e s , a n a t t i t u d e m a y be so d o m i n a n t o r
p e r v a s i v e t h a t d e s p i t e changes i n e n v i r o n m e n t a l events, t h e c o n c l u s i o n
n e v e r varies (e.g., " I c a n ' t be h a p p y unless I ' m l o v e d " ) . B y a r t i c u l a t i n g
C O G N I T I V E T H E R A P Y OF D E P R E S S I O N AND S U I C I D E 207

these a t t i t u d e s , t h e t h e r a p i s t h e l p s t h e p a t i e n t n o t o n l y t o d e v e l o p a basis
f o r e m p i r i c a l v a l i d a t i o n , b u t also t o r e c o g n i z e s u b s e q u e n t c o g n i t i o n s
based o n these a t t i t u d e s .
Cognitive t h e r a p y techniques are designed to facilitate changes i n
specific t a r g e t s y m p t o m s f o u n d i n d e p r e s s i o n (e.g., i n a c t i v i t y , self-
c r i t i c i s m , lack o f g r a t i f i c a t i o n , s u i c i d a l wishes.) T h e specific t e c h n i q u e s
are described i n detail elsewhere. 4
H e r e w e w i l l describe j u s t a f e w o f
these t e c h n i q u e s t o i l l u s t r a t e t h e n a t u r e o f t h e t r e a t m e n t .
I n g e n e r a l , a t h e r a p y session b e g i n s w i t h a discussion o f t h e f o r m e r l y
assigned h o m e w o r k . T h i s h o m e w o r k g e n e r a l l y focuses o n t h e p a t i e n t ' s
t h i n k i n g . T h e l a t t e r p a r t o f each session is s p e n t d e v e l o p i n g a n d p l a n -
n i n g the subsequent h o m e w o r k assignment.
I n t h e i n i t i a l sessions, t h e r a p y t e n d s t o e m p h a s i z e i n c r e a s e d a c t i v i t y
a n d e n v i r o n m e n t a l i n t e r a c t i o n (i.e., b e h a v i o r a l changes). I n t h e c o u r s e
o f s u c h changes, t h e p a t i e n t l e a r n s t o m o n i t o r a n d r e c o g n i z e his t h i n k i n g
i n r e g a r d to his b e h a v i o r o r a c t i v i t y . T h i s e a r l y e m p h a s i s o n b e h a v i o r a l
objectives is based o n o u r r e c o g n i t i o n t h a t t h e severely d e p r e s s e d p a t i e n t
is o f t e n u n a b l e t o e n g a g e i n c o g n i t i v e tasks because o f d i f f i c u l t y i n
abstract r e a s o n i n g .
A s t h e d e p r e s s i o n lessens, c o n c e n t r a t i o n i m p r o v e s a n d t h e i n t e n s i t y
o f t h e a f f e c t decreases. T h e p a t i e n t is t a u g h t t o collect, e x a m i n e , a n d
test his a u t o m a t i c t h o u g h t s (e.g., T r i p l e C o l u m n T e c h n i q u e b e l o w ) . I n
s u b s e q u e n t sessions, t h e a s s u m p t i o n s s u p p o r t i n g these c o g n i t i o n s a r e
identified a n d subjected to e m p i r i c a l validation t h r o u g h h o m e w o r k
assignments. These cognitive-change techniques r e q u i r e a greater
a b i l i t y t o abstract a n d use l o g i c . T h e r e f o r e , t h e y are e m p l o y e d a f t e r t h e
d e p r e s s i o n lessens i n s e v e r i t y . H o w e v e r , t h e t h e r a p i s t m a y e m p l o y
these c o g n i t i v e - c h a n g e t e c h n i q u e s f r o m t h e o u t s e t i f t h e p a t i e n t is o n l y
moderately depressed.
W e w i l l describe a t e c h n i q u e w i t h a p r i m a r y b e h a v i o r a l o b j e c t i v e (the
G r a d e d Task Assignment) a n d one w i t h a p r i m a r y cognitive objective
(the T r i p l e C o l u m n T e c h n i q u e ) . H o w e v e r , a task d e s i g n e d t o a l t e r
m a i n l y b e h a v i o r , w i l l also i n f l u e n c e t h e p a t i e n t ' s t h i n k i n g . S i m i l a r l y , a
c o g n i t i v e c h a n g e m a y r e s u l t i n a b e h a v i o r a l c h a n g e as w e l l .

Graded Task Assignment

T h e G r a d e d T a s k A s s i g n m e n t is based o n t h e a s s u m p t i o n t h a t t h e
d e p r e s s e d p a t i e n t has d i f f i c u l t y c o m p l e t i n g tasks w h i c h h a d b e e n r e l a -
t i v e l y s i m p l e , p r i o r t o t h e d e p r e s s i o n . A l t h o u g h t h e p a t i e n t has t h e s k i l l
a n d i n f o r m a t i o n necessary t o p e r f o r m t h e task, he e x p e r i e n c e s d i f f i c u l t y
w i t h i t because he t h i n k s " I c a n ' t d o a n y t h i n g " o r " I t ' s useless t o t r y . "
T h e e n d r e s u l t o f s u c h t h i n k i n g is decreased a c t i v i t y a n d f u r t h e r n e g a -
tive s e l f - e v a l u a t i o n . T h i s r e a c t i o n is a l o g i c a l r e s u l t o f a n o v e r -
208 A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

g e n e r a l i z e d b e l i e f t h a t "because a n activity is n o l o n g e r s i m p l e ,
t h e r e f o r e , i t is i m p o s s i b l e . " T h e c o g n i t i v e t h e r a p i s t a p p r o a c h e s this
p r o b l e m f r o m a n e m p i r i c a l v i e w p o i n t ( " W o u l d y o u be w i l l i n g t o test y o u r
belief?") r a t h e r t h a n t r y i n g t o t a k e a n o p p o s i n g s t a n d ("Yes, y o u c a n d o i t
i f y o u t r y . " ) since t h i s l a t t e r s t r a t e g y m a y a l i e n a t e t h e p a t i e n t . T h e
G r a d e d T a s k A s s i g n m e n t consists o f s u b d i v i d i n g t h e m a j o r task i n t o
m i n i - t a s k s w h i c h a r e w i t h i n t h e p a t i e n t ' s c a p a b i l i t y . T h u s , this t e c h -
n i q u e n o t o n l y increases a c t i v i t y by i n d u c i n g t h e p a t i e n t t o u n d e r t a k e
m o r e tasks b u t i t also h e l p s t h e p a t i e n t recognize a n d c o r r e c t u n r e a l i s -
tically n e g a t i v e c o g n i t i o n s w h i c h m a i n t a i n i n a c t i v i t y .
O t h e r t e c h n i q u e s d e s i g n e d t o c h a n g e b e h a v i o r i n c l u d e Activity
Scheduling (the p a t i e n t a n d t h e r a p i s t c o l l a b o r a t e t o s c h e d u l e h o u r l y
a s s i g n m e n t s ) ; t h e Mastery and Pleasure Technique ( s c h e d u l e d activities a r e
rated according to the a m o u n t o f mastery or pleasure obtained w i t h
each); a n d Cognitive Rehearsal (the p a t i e n t i m a g i n e s each step i n t h e se-
q u e n c e l e a d i n g to c o m p l e t i o n o f t h e a s s i g n m e n t ) . E a c h o f these t e c h -
n i q u e s is u s e d t o h e l p t h e p a t i e n t r e e v a l u a t e his i n i t i a l n e g a t i v e beliefs i n
h o p e s o f m a k i n g a n a p p r o p r i a t e c o g n i t i ve c h a n g e (e.g., " I thought t h a t I
c o u l d n ' t d o a n y t h i n g b u t t h e e v i d e n c e is t h a t t h e tasks are h a r d to d o b u t
n o t i m p o s s i b l e . " ) . I n u s i n g these t e c h n i q u e s t h e t h e r a p i s t emphasizes
the i m m e d i a t e goal o f r e l i e v i n g the patient's self-debasement.

Triple Column Technique

A n u m b e r o f specific t e c h n i q u e s a r e d e s i g n e d to h e l p t h e p a t i e n t
i d e n t i f y a n d r e e v a l u a t e his t h i n k i n g . F o r e x a m p l e , t h e T r i p l e C o l u m n
T e c h n i q u e is o f t e n used to h e l p t h e p a t i e n t t o i d e n t i f y a n d r e a l i t y test
u p s e t t i n g c o g n i t i o n s . T h e p a t i e n t r e c o r d s t h e events associated w i t h u n -
pleasant a f f e c t as w e l l as t h e a c t u a l c o g n i t i o ns o r a u t o m a t i c t h o u g h t s
associated w i t h t h e d y s p h o r i a . N e x t tfhe p a t i e n t a t t e m p t s t o a n s w e r
these c o g n i t i o n s u s i n g c o n c r e t e e v i d e n c e ("facts") t o test t h e v a l i d i t y a n d
reasonableness o f each c o g n i t i o n . T h e e v i d e n c e f o r a n d against each
specific t h o u g h t (e.g., " I ' m a c o m p l e t e f a i l u r e , " o r " E v e r y o n e is d i s g u s t e d
w i t h m e . " ) is e x a m i n e d . I n this w a y , t h e p a t i e n t l e a r n s to see his c o g n i -
t i o n s as p s y c h o l o g i c a l events o r responses r a t h e r t h a n as a n accurate
reflection o f reality. T h e t h e r a p i s t h e l p s t h e p a t i e n t c a t e g o r i z e his
c o g n i t i o n s u n d e r r e l e v a n t t h e m e s s u c h as s e l f - b l a m e , i n f e r i o r i t y , o r d e -
p r i v a t i o n . T h e p a t i e n t l e a r n s t h a t o f t(he m a n y ways t o i n t e r p r e t l i f e
experiences he tends to persevere i n a few stereotyped, self-defeating
patterns.
As t h e p a t i e n t distances h i m s e l f f r o)rti his a u t o m a t i c t h i n k i n g a n d as
he l e a r n s t o a n s w e r his d i s t o r t e d n e g a t i v e t h o u g h t s w i t h c o n c r e t e e v i -
d e n c e , he begins t o r e c o n c e p t u a l i z e p r o b l ems a n d t o d e v e l o p a l t e r n a t i v e
m e t h o d s o f p r o b l e m s o l v i n g . T h i s p r o b l e m s o l v i n g i n v o l v e s a search f o r
C O G N I T I V E T H E R A P Y O F D E P R E S S I O N AND S U I C I D E 209

alternative interpretations a n d s o l u t i o n s t o p r o b l e m a t i c events.

T h e r a p y is n o t s i m p l y t h i n k i n g p o s i t i v e l y b u t r a t h e r t h i n k i n g realistically
a n d logically.
T h e l a t t e r stages o f c o g n i t i v e t h e r a p y i n v o l v e i d e n t i f i c a t i o n o f
chronic attitudes a n d assumptions by w h i c h t h e patient constructs a n d
o r d e r s his e x p e r i e n t i a l w o r l d . T h e c o n t e n t o f these a t t i t u d e s is i n f e r r e d
f r o m the r e c u r r e n t themes present i n t h e patient's cognitive response to
specific s i t u a t i o n s . S o m e o f t h e a t t i t u d e s f o u n d t o be associated w i t h
d e p r e s s i o n i n c l u d e n o t i o n s s u c h as: " I m u s t be successful i n w h a t e v e r I
u n d e r t a k e " ; " M y v a l u e as a p e r s o n d e p e n d s o n w h a t o t h e r s t h i n k o f m e " ;
a n d " I c a n ' t live w i t h o u t l o v e . " T h e p a t i e n t learns t o e x a m i n e a n d assess
t h e reasonableness o f these basic a t t i t u d e s b y c o n s i d e r i n g t h e e v i d e n c e
f o r a n d against e a c h b e l i e f . H e is o f t e n a s k e d t o u n d e r t a k e h o m e w o r k
to test o u t t h e v a l i d i t y o r t h e g e n e r a l a p p l i c a b i l i t y o f a specific a t t i t u d e .
T h e f o l l o w i n g case e x a m p l e serves t o i l l u s t r a t e a n u m b e r o f t h e
specific i n g r e d i e n t s i n c o g n i t i v e t h e r a p y . T h e case h i s t o r y is p r e s e n t e d
to e x e m p l i f y p r a c t i c a l issues i n d i f f e r e n t i a l diagnosis a n d t r e a t m e n t
planning. I n a p p l y i n g c o g n i t i v e t h e r a p y t o a specific p a t i e n t , t h e
t h e r a p i s t j u d i c i o u s l y selects t e c h n i q u e s f r o m a v a r i e t y o f possibilities.
T h e basic g u i d e l i n e s f o r t h e selection o f t h e m o s t p e r t i n e n t t e c h n i q u e s
are d e t a i l e d e l s e w h e r e . T h i s case e x a m p l e i l l u s t r a t e s t h e use o f a f e w o f
6

the many techniques o f cognitive therapy.

CASE REPORT
Mr. L . , a 5 2 - y e a r - o l d , m a r r i e d f a t h e r o f t w o , r e t i r e d n a v a l officer, w a s self-
referred. H e sought treatment stating " M a y b e I a m a manic-depressive a n d
need lithium." H e complained o f guilt, difficulty concentrating, suicidal ide-
ation, e a r l y - m o r n i n g a n dsleep-onset insomnia, anorexia, a fifteen-pound weight
loss, social w i t h d r a w a l , d e c r e a s e d libido, i n t e r m i t t e n t i m p o t e n c y , lack o f interest
in f o r m e r l y enjoyable activities, a n d m i l d p s y c h o m o t o r retardation. Although
h e h a d n o history o f a l c o h o l a d d i c t i o n , h e h a d b e e n g i v e n to excessive d r i n k i n g
since the onset o f the depression.
His depression h a d been triggered three years previously when h e dis-
c o v e r e d his wife's e x t r a m a r i t a l affair w i t h a fellow officer. H i s wife terminated
the affair w h e n M r . L . f o u n d out. A year later h e h a d resigned f r o m the service
as a c o n s e q u e n c e o f his d e p r e s s i o n .
H e b e l i e v e d h e h a d f o r c e d h i s wife to stay w i t h h i m b y h i s d i s c o v e r y , a l t h o u g h
there w a s n o e v i d e n c e , e v e n after several interviews w i t h h e r that this w a s a valid
belief. S h e stated s h e c h o s e to stay w i t h h i m b e c a u s e s h e l o v e d h i m . S h esaw
the affair as a s y m p t o m o f difficulties i n t h e r e l a t i o n s h i p . H e spent most o f his
waking moments thinking about the affair w h i c h h e interpreted i n terms o f per-
sonal failure a n d inadequacy.
H e h a d h a d two other episodes o f the depressive s y n d r o m e i n the past. Each
episode lasted o n e year, each remitted without formal treatment, a n d each was
210 AMERICAN J O lJ R N A L OF PSYCHOTHERAPY

associated with the failure to get p r o m o t e d c n time. E a c h o f these events was

c o n s t r u e d by the patient as testimony to his in< : o m p e t e n c e .
T h e r e was also suggestive e v i d e n c e o f h y p o m a n i c episodes w i t h i n c r e a s e d
activity, e u p h o r i a , e n e r g y a n d feelings o f ere ativity, but these episodes failed to
meet criteria for h y p o m a n i a . T h e patient p r e s e n t e d e v i d e n c e by history a n d
6

mental status o f obsessive-compulsive p e r tonality. H e showed significant

c o n c e r n over issues o f respect, c o n t r o l , a n d tir ne.
Treatment consisted of both chemotherapy a n d cognitive therapy
administered simultaneously. H o u r l y ses lions o f cognitive therapy were
c o n d u c t e d o n c e weekly for a total o f 16 sess ions. C h e m o t h e r a p y consisted o f
a m i t r i p t y l i n e m a i n t a i n e d at 1 0 0 - 1 5 0 mg/da} until t h e 16th w e e k o f t r e a t m e n t
T

w h e n it was d i s c o n t i n u e d . T h e t h e r a p y s issions initially i n c l u d e d only the

patient b u t subsequently i n c l u d e d his spouse as well. T h e patient's r e s p o n s e to
this c o m b i n a t i o n a p p r o a c h , a c c o r d i n g to the B e c k D e p r e s s i o n I n v e n t o r y , ( B D I )
is s h o w n i n T a b l e 1.

T A B L E 1:

Week No. Initial 2 5 6 8 10 12 16 24

BDI 19 10 7 4 5 1 0 2 7

C h e m o t h e r a p y was u s e d i n h o p e s o f p r o v i d i n g r a p i d s y m p t o m a t i c r e l i e f as
the patient a p p e a r e d very s u i c i d a l a n d h o p e ess at t h e b e g i n n i n g o f t r e a t m e n t .
Hospitalization a p p e a r e d i m m i n e n t i f symptq >matic r e l i e f c o u l d not be p r o v i d e d
rapidly. W e also h o p e d , by r e s p o n d i n g to the patient's e x p e c t a t i o n f o r , a n d
indeed, near insistence on drug treatme i t , to create a milieu in which
psychological t r e a t m e n t might be a c c e p t e d at east as a n a d j u n c t t r e a t m e n t ,
C o g n i t i v e t h e r a p y was d e s i g n e d to h e l p t tie patient: (1) identify a n d r e c o r d
his negative automatic t h i n k i n g ; (2) identify < t i m u l i w h i c h t r i g g e r e d these n e g a -
tive t h o u g h t s ; (3) p r o v i d e m e t h o d s to coii t r o l these t h o u g h t s ; (4) p r o v i d e
m e t h o d s for the patient to refute a n d c o r r e ct these t h o u g h t s ; a n d (5) identify
and c o r r e c t the silent a s s u m p t i o n s o r themeis w h i c h r a n t h r o u g h o u t a n d s u p -
p o r t e d his negative t h i n k i n g .
Step 1: T h e patient r e c o r d e d his negativ< i thoughts a n d associated e n v i r o n -
m e n t a l events i n his notebook. H e r e p o r t e c a p r o f u s i o n o f negative automatic
thoughts o r cognitions. T h e s e cognitions we r e repetitious, u p s e t t i n g , d i s t o r t e d ,
a n d generally reflected a very negative view o f h i m s e l f . T h e content consisted
o f statements s u c h as, " I a m a failure i n m y o c c u p a t i o n . M y wife has s h o w n m e
I ' m a failure i n m a r r i a g e . I can't get a j o b ir i civilian life. N o o n e respects m e .
I've n e v e r s u c c e e d e d at a n y t h i n g .
W h y botl ler to a p p l y f o r a j o b , they'll n e v e r
h i r e s o m e o n e as old as I a m . I can't e v e n pla> tennis a n y m o r e , " a n d so forth,
Step 2: B y r e c o r d i n g the e n v i r o n m e n t a l ev ents associated w i t h negative t h i n k -
i n g , the patient identified s t i m u l i for this ti l i n k i n g . Exacerbating stimuli i n -
e l u d e d p l a y i n g t e n n i s , h a v i n g d i n n e r w i t h hii wife, a n d l o o k i n g at o l d N a v y p i c -
tures. D r i n k i n g alcohol o r w a l k i n g i n the wc ods alone d e c r e a s e d the f r e q u e n c y
o f the thoughts. T h e patient's c o n c e n t r a t i oi was severely i m p a i r e d because o f
this r e c u r r e n t s t r e a m o f self-critical t h i n k i n g .
C O G N I T I V E T H E R A P Y OF D E P R E S S I O N AND S U I C I D E 211

Step 3: T h e patient u s e d a wrist c o u n t e r to m o n i t o r the f r e q u e n c y o f these

thoughts a n d the s t i m u l i associated with t h e m . O n the a v e r a g e , these thoughts
o c c u r r e d about 60 times p e r h o u r d u r i n g most o f the day.
T h e patient was i n s t r u c t e d to r e c o r d a n d g r a p h the exact n u m b e r o f negative
thoughts p e r m i n u t e for f o u r days for every w a k i n g m i n u t e u s i n g a stopwatch
and counter. W i t h this t e c h n i q u e he r e d u c e d the thoughts to as few as 3 to 7 p e r
hour. H e g a i n e d some c o n t r o l o v e r his thoughts with this t e c h n i q u e . I n addi-
tion, he b e g a n to look at his t h i n k i n g m o r e objectively (i.e., to r e g a r d these
thoughts as u p s e t t i n g yet repetitious psychological events, r a t h e r t h a n a c c u r a t e
reflections o f reality).
Step 4: A f t e r he l e a r n e d to c o n t r o l a n d to b e c o m e m o r e objective about his
negative t h o u g h t s , he was able to begin to c o r r e c t , validate, a n d / o r refute e a c h
thought. W h e n a s k e d for e v i d e n c e that these thoughts w e r e t r u e , he r e p e a t e d
the p r e v i o u s e x p e r i e n c e s o f d e l a y e d p r o m o t i o n , f a i l u r e to m a k e A d m i r a l , a n d
his c u r r e n t difficulty w i t h s e x u a l p e r f o r m a n c e . H e felt his wife was too a s h a m e d
o f h e r affair to seek a d i v o r c e . T h i s i n f e r e n c e e x p l a i n e d w h y she was still l i v i n g
w i t h h i m w h e n he believed she still loved h e r f o r m e r p a r a m o u r . Furthermore,
the p a r a m o u r h a d b e e n o f a h i g h e r r a n k t h a n the patient. T h i s fact was seen by
the patient as e v i d e n c e that he wasn't g o o d e n o u g h for h e r . H e saw his wife as a
b r i g h t , attractive, t a l e n t e d , artistic, a n d m u c h a d m i r e d a n d r e s p e c t e d w o m a n .
I n c o m p a r i s o n , he saw h i m s e l f as a n o c c u p a t i o n a l , m a r i t a l , s e x u a l , a n d social
f a i l u r e . H e attributed his m a n y military h o n o r s to " t h e s y s t e m , " w h i l e he at-
tributed occupational failures to himself. I n r e v i e w i n g these thoughts he
l e a r n e d to identify a n d c o r r e c t the cognitive distortions o f o v e r g e n e r a l i z a t i o n ,
a r b i t r a r y i n f e r e n c e , a n d magnification.
H e l e a r n e d to identify specific t h e m e s w h i c h w e r e i n f e r r e d f r o m the negative
automatic thoughts he r e c o r d e d . H e l e a r n e d to evaluate these t h e m e s w i t h logic
a n d , at times, with e x p e r i m e n t a l testing. E x a m p l e s o f these t h e m e s are " U n l e s s
I do e v e r y t h i n g perfectly, I ' m a f a i l u r e . I f I a m not r e w a r d e d a n d r e s p e c t e d ,
I'm a failure. I f I m a k e a mistake, it m e a n s I ' m defective. B e c a u s e my wife h a d
an affair, she no l o n g e r loves o r respects m e . I can't enjoy a n y t h i n g i f I ' m not
the best."
Initially, the patient e n u m e r a t e d a p l e t h o r a o f specific events f r o m his past,
e a c h o f w h i c h he c o n s t r u e d as s u p p o r t i n g these t h e m e s . O f t e n his e v i d e n c e
w e n t back five to twenty-five years p r i o r to t r e a t m e n t . B y r e v i e w i n g the e v i -
d e n c e point by point a n d suggesting alternative i n t e r p r e t a t i o n s o f the events
reported, enough doubt developed i n the patient's t h i n k i n g , that he w o u l d
consider r u n n i n g an experiment to test the a s s u m p t i o n or theme under
consideration. F o r e x a m p l e , he was d i r e c t e d to intentionally lose at s e v e r a l sets
o f tennis with a m e d i o c r e p l a y e r , w h i l e t r y i n g to identify w h a t else he m i g h t be
enjoying while playing. He reported enjoying the e x e r c i s e , c o n v e r s a t i o n ,
w e a t h e r , a n d o t h e r players at the c l u b , thereby d i s e n t a n g l i n g the issues o f
achievement and enjoyment.
H e l e a r n e d to see his wife's affair m o r e as a reflection o f h e r view o f h e r s e l f
and the m a r r i a g e r a t h e r t h a n c o n c l u s i v e p r o o f o f some p e r m a n e n t defect i n
himself. B y l e a r n i n g how he h a d i n a d v e r t e n t l y b l o c k e d c o m m u n i c a t i o n (at least
f r o m his wife's v i e w p o i n t ) , he c o u l d take corrective action to discuss a n d solve
212 A M E R I C A N J OU R N A L OF P S Y C H O T H E R A P Y

problems rather than c o n c l u d i n g that he 1

5 a total failure by o v e r g e n e r a l i z i n g
f r o m a few complaints f r o m his wife.
At s i x - m o n t h follow-up, the patient's B e c k D e p r e s s i o n Inventory was six.
H e was taking no medication. H e w a s e m p l o y e d f u l l t i m e , still m a r r i e d a n d n o t
drinking excessively. He a n d his wife r e p o r t e d a d r a m a t i c i m p r o v e m e n t in
marital satisfaction.

T h i s case i l l u s t r a t e s t h e use o f c o m b i n e d c h e m o t h e r a p y a n d c o g n i t i v e
therapy. T h e c o m b i n a t i o n t r e a t m e n t may have certain advantages.
C h e m o t h e r a p y m a y p r o v i d e r a p i d s y m p t o m a t i c r e l i e f (e.g, f o r i n s o m n i a )
a n d i t m a y s u f f i c i e n t l y m a t c h t h e p a t i e m ;'s e x p e c t a t i o n s , so t h a t c o g n i t i v e
a n d b e h a v i o r a l c h a n g e t e c h n i q u e s can be a p p l i e d . C o g n i t i v e t h e r a p y
m a y have r e s u l t e d i n s u f f i c i e n t c o r r e c t i o n o f h o w t h i s p a t i e n t c h r o n i c a l l y
gives d i s t o r t e d n e g a t i v e m e a n i n g s t o events b o t h past a n d p r e s e n t , t o
p r o v i d e p r o p h y l a x i s against f u t u r e depr^ssio ns.
F u r t h e r m o r e , this case i l l u s t r a t e s h o w a c o g n i t i v e o r b e h a v i o r a l a p -
p r o a c h can i n v o l v e t h e c o u p l e o r f a m i l y system. O f t e n t h e spouse can
p r o v i d e i n f o r m a t i o n to correct cognitive d i s t o r t i o n s . 7
F u r t h e r m o r e , as
t h e spouse becomes a w a r e o f t h e p a t i e n t s n e g a t i v e t h i n k i n g , h e o r she
can r e s o r t t o v e r b a l a n d n o n v e r b a l b e h a v i o r s t o c o n s i s t e n t l y " d i s " c o n f i r m
the patient's negative automatic t h i n k i n g

O U T C O M E S T U D I E S OF C O G N I T I V E T H E R A P Y
W e have b r i e f l y p r e s e n t e d t h e c o g n i t i v e m o d e l o f d e p r e s s i o n . This
m o d e l has b e e n a basis f o r d e v e l o p i n g a specific c o g n i t i v e t h e r a p y f o r
depression. T h e r a t i o n a l e f o r t h e co; ^nitive t h e r a p y o f d e p r e s s i o n is
d e r i v e d f r o m this f o r m u l a t i o n : i f t h e s o u r c e o f t h e d e p r e s s i o n is a h y p e r -
v a l e n t set o f n e g a t i v e c o n c e p t s , t h e n t h e c o r r e c t i o n a n d d a m p i n g d o w n
o f these schemas m a y be e x p e c t e d to alleviate t h e depressive s y m p t o -
m a t o l o g y . I n c o g n i t i v e t h e r a p y , t h e the r a p i s t a n d p a t i e n t w o r k t o g e t h e r
t o i d e n t i f y d i s t o r t e d c o g n i t i o n s , d e r i v e f r o m his d y s f u n c t i o n a l beliefs,
T h e s e d i s t o r t e d n e g a t i v e c o g n i t i o n s a n d d y s f u n c t i o n a l beliefs a r e s u b -
j e c t e d to l o g i c a l analysis a n d e m p i r i c a l t e s t i n g . M o r e o v e r , t h r o u g h t h e
a s s i g n m e n t o f b e h a v i o r a l tasks, t h e p a t i e n t l e a r n s t o m a s t e r p r o b l e m s
a n d life situations w h i c h he previously considered insuperable, a n d con-
s e q u e n t l y , h e learns t o r e a l i g n his t h i n k i n g w i t h r e a l i t y .
Studies o f t h e efficacy o f c o g n i t i v e t h e r a p y have i m p l i c a t i o n s f o r t h e
cognitive model. I f t e c h n i q u e s t o cor|rect c o g n i t i o n s o f f e r n o specific
a d v a n t a g e o v e r n o t r e a t m e n t o r n o n specificc t r e a t m e n t c o n t r o l s , we
m i g h t c o n c l u d e t h a t n e g a t i v e c o g n i t i o n , a l t h o u g h p r e s e n t i n association
w i t h a d e p r e s s e d m o o d , m a y s i m p l y be ; s e c o n d a r y e f f e c t o f t h e m o o d i t -
self, a n e p i p h e n o m e n o n , r a t h e r t h a n h k v i n g a causal r e l a t i o n s h i p to t h e
disorder. Secondly, i f d y s f u n c t i o n a l attitudes c o n t r i b u t e to a predis-
C O G N I T I V E T H E R A P Y OF D E P R E S S I O N AND S U I C I D E 213

p o s i t i o n t o d e p r e s s i o n a n d i f these a t t i t u d e s are c o r r e c t e d w i t h c o g n i t i v e
t h e r a p y , t h e n p a t i e n t s t r e a t e d w i t h c o g n i t i v e t h e r a p y m a y be a f f o r d e d
some p r o p h y l a x i s against relapse c o m p a r e d to n o t r e a t m e n t o r p e r h a p s
to other treatments.
A n u m b e r o f o u t c o m e studies c o m p a r i n g t h e efficacy o f c o g n i t i v e
t h e r a p y w i t h o t h e r t r e a t m e n t s f o r d e p r e s s i o n are n o w available. To
date t h r e e c o n t r o l l e d o u t c o m e studies w i t h d e p r e s s e d s t u d e n t s h a v e
been c o n d u c t e d , two o f w h i c h used a g r o u p - t r e a t m e n t f o r m a t . Cogni-
t i v e t h e r a p y e x c e e d e d t h e results o b t a i n e d i n w a i t i n g - l i s t , s u p p o r t i v e -
treatment, or positive-experience control groups.
S h i p l e y a n d F a z i o t r e a t e d t w e n t y - f o u r subjects w i t h a n i n d i v i d u a l
8

approach w h i c h p r o v i d e d functional problem-solving alternatives.

T w e n t y - f i v e depressed controls received a nonspecific interest-support
treatment. T h e experimental treatment resulted i n significantly greater
i m p r o v e m e n t t h a n t h e c o n t r o l t r e a t m e n t . I n a d d i t i o n , these effects
w e r e i n d e p e n d e n t o f the subjects' i n i t i a l expectancies.
Taylor and Marshall conducted a controlled-treatment compari-
9

son a m o n g g r o u p s w h i c h r e c e i v e d c o g n i t i v e m o d i f i c a t i o n , b e h a v i o r
m o d i f i c a t i o n , c o g n i t i v e and b e h a v i o r m o d i f i c a t i o n , as w e l l as a w a i t i n g list
g r o u p . T h e y f o u n d t h a t p a t i e n t s i n a l l active t r e a t m e n t g r o u p s s h o w e d
s i g n i f i c a n t i m p r o v e m e n t i n d e p r e s s i o n c o m p a r e d to t h e w a i t i n g - l i s t c o n -
t r o l subjects. T h e c o m b i n a t i o n t r e a t m e n t was s u p e r i o r to t h e c o g n i t i v e
a n d the behavioral treatments alone.
Gioe 1 0
compared a modified cognitive-modification treatment in
combination w i t h a "positive g r o u p experience," a cognitive-modifica-
tion t r e a t m e n t , a treatment consisting o f a "positive g r o u p experience"
alone a n d a waiting-list c o n t r o l . U s i n g a g r o u p - t h e r a p y m o d a l i t y w i t h
t e n d e p r e s s e d s t u d e n t s i n each g r o u p , he r e p o r t e d t h a t t h e c o m b i n a t i o n
t r e a t m e n t p a c k a g e was clearly s u p e r i o r i n a l l e v i a t i n g depressive s y m p -
tomatology.
T u r n i n g t o studies o f c o g n i t i v e t h e r a p y i n d e p r e s s e d p s y c h i a t r i c
p a t i e n t s , we find a t o t a l o f f o u r c o n t r o l l e d o u t c o m e studies a n d t h r e e
case r e p o r t s . C o g n i t i v e t h e r a p y has e x c e e d e d t h e results o f w a i t i n g - l i s t
g r o u p , insight therapy, behavior therapy, nondirective therapy, and
pharmacotherapy.
S h a w treated depressed patients r e f e r r e d f r o m a University H e a l t h
1 1

Service. Psychometric ratings, self-reports, a n d i n d e p e n d e n t clinical

e v a l u a t i o n s w e r e u s e d . A g r o u p - t h e r a p y f o r m a t was e m p l o y e d w i t h o n e
t h e r a p i s t t r e a t i n g e i g h t subjects i n each g r o u p . A l l active t r e a t m e n t s
p r o d u c e d s i g n i f i c a n t l y b e t t e r results t h a n a w a i t i n g - l i s t c o n t r o l . Cogni-
t i v e t h e r a p y was f o u n d t o be m o r e efficacious t h a n b e h a v i o r t h e r a p y ( i n -
t e r p e r s o n a l skills t r a i n i n g ) , n o n d i r e c t i v e t h e r a p y , a n d a w a i t i n g - l i s t c o n -
trol.
214 A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

Rush a n d c o w o r k e r s r e p o r t e d o n cognitive therapy o f three patients

7

w i t h chronic relapsing depression. T h e main behavioral modality

consisted o f t h e use o f a c t i v i t y schedules. T h e c o g n i t i v e a p p r o a c h was
d i r e c t e d at e x p o s i n g a n d c o r r e c t i n g t h e p a t i e n t ' s n e g a t i v e m i s e v a l u a t i o n s
o f his activities. T h e s e p a t i e n t s , a l t h o u g h n o t p r e v i o u s l y h e l p e d by d r u g
t h e r a p y , s h o w e d p r o m p t a n d s u s t a i n e d i m p r o v e m e n t w i t h t h e r a p y ac-
c o r d i n g to c l i n i c a l a n d s e l f - r e p o r t measures.
Morris 1 2
compared a "didactic cognitive behavioral p r o g r a m , " an
" i n s i g h t - o r i e n t e d t h e r a p y " (an e x p e r i e n t i a l a n d u n s t r u c t u r e d p r o g r a m
w h i c h focused o n self-understanding), a n d a waiting-list c o n t r o l g r o u p
w i t h d e p r e s s e d f e m a l e o u t p a t i e n t s . T w e n t y - t w o subjects w e r e t r e a t e d i n
t h e c o g n i t i v e - b e h a v i o r a l g r o u p , seventeen i n t h e i n s i g h t g r o u p a n d
t w e l v e served as c o n t r o l s . T h e c o g n i t i v e - b e h a v i o r a l p r o g r a m was s u p e -
r i o r . F u r t h e r m o r e , t h e c o g n i t i v e - b e h a v i o r a l t r e a t m e n t was as e f f e c t i v e
i n a t h r e e - w e e k p e r i o d as i n a six-week p e r i o d w h e n t h e n u m b e r o f
sessions r e m a i n e d c o n s t a n t . T h i s l a t t e r f i n d i n g emphasizes a n o t a b l e
4

f e a t u r e o f t h e c o g n i t i v e a p p r o a c h (i.e., s i g n i f i c a n t c h a n g e can o c c u r d u r -
ing a brief time period).
U s i n g a single-subject d e s i g n , S c h m i c k l e y , r e p o r t e d significant
13

i m p r o v e m e n t i n eleven c l i n i c a l o u t p a t i e n t s as a d i r e c t r e s u l t o f f o u r o n e -
h o u r sessions o f c o g n i t i v e - b e h a v i o r a l t r e a t m e n t i n t e r v e n t i o n . A t t e r m i -
n a t i o n , i m p r o v e m e n t was f o u n d w i t h eleven o f t w e l v e p s y c h o m e t r i c a n d
b e h a v i o r a l measures.
W e r e c e n t l y u n d e r t o o k a n i n t e n s i v e p i l o t s t u d y at t h e U n i v e r s i t y o f
Pennsylvania. 14
W e c o m p a r e d t h e r e l a t i v e efficacy o f c o g n i t i v e t h e r a p y
w i t h a tricyclic antidepressant d r u g ( i m i p r a m i n e h y d r o c h l o r i d e ) i n the
t r e a t m e n t o f f o r t y - o n e d e p r e s s e d o u t p a t i e n t s . C o g n i t i v e t h e r a p y was
f o u n d t o be m o r e e f f e c t i v e t h a n i m i p r a m i n e .
W e have r e c e n t l y e x t e n d e d o u r s t u d y to f o r t y - f o u r d e p r e s s e d o u t -
p a t i e n t s , a n d f o l l o w - u p d a t a a r e n o w available. A l l p a t i e n t s w e r e self-
r e f e r r e d p s y c h i a t r i c o u t p a t i e n t s w h o satisfied r e s e a r c h d i a g n o s t i c c r i t e r i a
f o r t h e depressive s y n d r o m e . 6
A l l h a d a diagnosis o f d e p r e s s i v e
n e u r o s i s a c c o r d i n g t o t h e D i a g n o s t i c Statistical M a n u a l - I I . 1 5
As a g r o u p
t h e y w e r e g e n e r a l l y w h i t e , p a r t i a l l y college e d u c a t e d , a n d i n t h e i r m i d -
thirties.
T h e i r past h i s t o r i e s a n d M i n n e s o t a M u l t i p h a s i c P e r s o n a l i t y I n v e n -
tories indicated a substantial degree o f psychopathology. I n general,
the patients h a d been i n t e r m i t t e n t l y o r chronically depressed almost
n i n e years, a n d o n e - f o u r t h o f these p a t i e n t s h a d b e e n h o s p i t a l i z e d f o r
d e p r e s s i o n i n t h e past. T h e a v e r a g e p a t i e n t h a d seen o v e r t w o
therapists p r i o r to the study. O n the average, the c u r r e n t episode o f
d e p r e s s i o n h a d b e e n p r e s e n t f o r j u s t less t h a n t w e l v e m o n t h s at t h e t i m e
o f e n t e r i n g the study. A t t h e start o f t r e a t m e n t , a l l p a t i e n t s w e r e
 C O G N I T I V E T H E R A P Y O F D E P R E S S I O N A N D S U I C I D E 215

m o d e r a t e - s e v e r e l y d e p r e s s e d by s e l f - r e p o r t (Beck D e p r e s s i o n I n v e n -
t o r y ) , o b s e r v e r e v a l u a t i o n ( H a m i l t o n R a t i n g Scale), a n d t h e r a p i s t r a t -
1 6 7

i n g (Raskin Scale). 18
Seventy-five p e r c e n t o f these p a t i e n t s r e p o r t e d
s i g n i f i c a n t s u i c i d a l i d e a t i o n at t h e start o f t r e a t m e n t . I n essence, o u r
u n i p o l a r depressed patients generally h a d a substantial degree o f
p s y c h o p a t h o l o g y and a h i s t o r y oí poor r e s p o n s e t o o t h e r p s y c h o t h e r a p i e s .
Patients w e r e r a n d o m l y assigned to e i t h e r i n d i v i d u a l c o g n i t i v e
therapy o r p h a r m a c o t h e r a p y ( i m i p r a m i n e h y d r o c h l o r i d e ) f o r twelve
weeks o f t r e a t m e n t . P r e s c r i b e d p s y c h o t h e r a p y consisted o f t w i c e
^weekly h o u r - l o n g c o g n i t i v e t h e r a p y sessions f o r a m a x i m u m o f t w e n t y
visits. P h a r m a c o t h e r a p y consisted o f n o t less t h a n 100 m g / d a y , b u t n o t
m o r e t h a n 250 mg/day o f i m i p r a m i n e prescribed i n t w e n t y - m i n u t e , once
w e e k l y visits f o r a m a x i m u m o f t w e l v e weeks.
T h e r a p i s t s consisted m a i n l y o f p s y c h i a t r i c r e s i d e n t s w h o h a d t r e a t e d
o n l y t w o " p r a c t i c e " cases w i t h s u p e r v i s i o n p r i o r t o t r e a t i n g r e s e a r c h
cases. T h e m e t h o d o l o g y o f c o g n i t i v e t h e r a p y was specified i n a t r e a t -
ment manual. 4
T h e t h e r a p i s t s w e r e systematically s u p e r v i s e d o n a
w e e k l y basis b y t h r e e e x p e r i e n c e d c l i n i c i a n s . A l l sessions w e r e a u d i o -
r e c o r d e d a n d spot c h e c k e d f o r a d h e r e n c e t o p r o t o c o l .
B o t h t r e a t m e n t g r o u p s w e r e e q u i v a l e n t w i t h respect t o d e m o g r a p h i c
c h a r a c t e r i s t i c s , h i s t o r i e s o f illness, t r e a t m e n t a n d m e a n severity o f
d e p r e s s i o n at t h e start o f t r e a t m e n t . O f n i n e t e e n p a t i e n t s assigned t o
cognitive therapy, eighteen completed treatment over a mean p e r i o d o f
eleven weeks. O f t w e n t y - f i v e p a t i e n t s assigned to p h a r m a c o t h e r a p y ,
seventeen c o m p l e t e d t r e a t m e n t o v e r t h e same m e a n p e r i o d o f t i m e .
By t h e e n d o f active t r e a t m e n t , b o t h t r e a t m e n t g r o u p s s h o w e d statis-
tically s i g n i f i c a n t decreases (p < .001) i n depressive s y m p t o m a t o l o g y ac-
c o r d i n g to self-reports, observer evaluations, a n d therapist ratings. By
the e n d o f t r e a t m e n t , cognitive t h e r a p y resulted i n significantly greater
i m p r o v e m e n t t h a n d i d p h a r m a c o t h e r a p y o n self-reports a n d observer-
based c l i n i c a l r a t i n g s o f d e p r e s s i o n ( < .01). T h e r e s p o n s e rates t o b o t h
p h a r m a c o t h e r a p y a n d cognitive t h e r a p y exceeded the usually r e p o r t e d
degree o f response to placebo i n depressed o u t p a t i e n t s . I n addition,
1 9

b o t h t r e a t m e n t s r e s u l t e d i n s u b s t a n t i a l decreases i n subjective r e p o r t s
and interviewer-based ratings o f anxiety.
I n t e r e s t i n g l y , t h e d r o p o u t r a t e d u r i n g active t r e a t m e n t was
significantly greater w i t h p h a r m a c o t h e r a p y t h a n w i t h cognitive therapy
(p < .05). H o w e v e r , e v e n w h e n these d r o p o u t s w e r e e l i m i n a t e d f r o m
t h e d a t a analysis, c o g n i t i v e t h e r a p y p a t i e n t s s h o w e d a s i g n i f i c a n t l y
g r e a t e r i m p r o v e m e n t i n depressive s y m p t o m a t o l o g y t h a n t h e p h a r m a -
c o t h e r a p y p a t i e n t s (p < .05).
F o l l o w - u p d a t a at t h r e e a n d six m o n t h s a f t e r t e r m i n a t i o n o f t r e a t -
m e n t f o r those w h o c o m p l e t e d c o g n i t i v e t h e r a p y a n d p h a r m a c o t h e r a p y
216 A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

40

Active Treatment Follow-Up

Q
CD 32

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> 24
n.
c:
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1/5
16
CD
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Drug (n = 17)
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o 8 Cognitive (n = 18)
CD
CÛ

0 J-
Evaluation Termination 3-Month 6-Month
Follow-Up Follow-Up
FIGURE I
SEVERITY O F D E P R E S S I O N D U R I N G T R E A T M E N T AND SIX-MONTH
F O L L O W - U P FOR P A T I E N T S C O M P L E T I N G T R E A T M E N T

a r e s h o w n i n F i g u r e 1. T r e a t m e n t gains w e r e m a i n t a i n e d f o r b o t h
groups. A greater n u m b e r o f the d r u g - t r e a t m e n t g r o u p r e t u r n e d to
t r e a t m e n t d u r i n g this p e r i o d c o m p a r e d t o c o g n i t i v e - t h e r a p y p a t i e n t s .
T h e c o g n i t i v e - t h e r a p y p a t i e n t s s h o w e d s i g n i f i c a n t l y l o w e r levels o f
d e p r e s s i o n at t h r e e m o n t h s (p < .05) a n d a t r e n d t o w a r d l o w e r levels at
six m o n t h s (p < .10).
A l s o those p a t i e n t s w h o h a d d r o p p e d o u t o f b o t h c o g n i t i v e t h e r a p y
a n d p h a r m a c o t h e r a p y w e r e f o l l o w e d u p at t h r e e a n d six m o n t h s a f t e r
t h e y w o u l d have c o m p l e t e d t r e a t m e n t . W h e n b o t h those w h o c o m -
p l e t e d a n d those w h o d r o p p e d o u t o f t h e r a p y a r e c o m b i n e d i n a c o m -
parison o f cognitive therapy and pharmacotherapy groups, cognitive
t h e r a p y r e s u l t e d i n statistically s i g n i f i c a n t l o w e r levels o f d e p r e s s i o n at
b o t h t h r e e m o n t h s (p < .05) a n d six m o n t h s o f f o l l o w - u p (p < .05).
T h i s is t h e first s t u d y t o s h o w t h a t a n y p s y c h o t h e r a p y was e q u i v a l e n t
t o o r e x c e e d e d t h e efficacy o f p h a r m a c o t h e r a p y i n t h e r e l i e f o f t h e acute
s y m p t o m s o f t h e depressive s y n d r o m e . O f c o u r s e , o u r results a w a i t
c o n f i r m a t i o n . I n a d d i t i o n , o u r f o l l o w - u p data indicated that t r e a t m e n t
gains are m a i n t a i n e d o v e r t i m e . O u r p r e l i m i n a r y d a t a suggest t h a t
C O G N I T I V E T H E R A P Y OF D E P R E S S I O N AND S U I C I D E 217

c o g n i t i v e t h e r a p y m a y e x c e e d p h a r m a c o t h e r a p y i n p r e v e n t i n g relapse
o r n e e d f o r f u r t h e r t r e a t m e n t , o n c e b o t h t r e a t m e n t s are d i s c o n t i n u e d
since a g r e a t e r n u m b e r o f p h a r m a c o t h e r a p y p a t i e n t s r e t u r n e d t o t r e a t -
m e n t d u r i n g f o l l o w - u p c o m p a r e d t o t h e c o g n i t i v e t h e r a p y cases.
Several o t h e r s t u d i e s ' have c o m p a r e d d i f f e r e n t p s y c h o t h e r a p i e s
2 0 2 2

directly or indirectly w i t h antidepressant pharmacotherapy i n the treat-

m e n t o f depressed outpatients. T h e psychotherapies studied i n c l u d e d
interpersonal t h e r a p y , marital t h e r a p y , a n d supportive-expressive
2 0 2 1

group treatments. 2 2
These psychotherapies d i d not compare w i t h the
efficacy o f a n t i d e p r e s s a n t m e d i c a t i o n i n t h e r e l i e f o f t h e acute s y m p t o m s
o f t h e depressive s y n d r o m e . T h e s e studies also i n d i c a t e t h a t t h e
increased a m o u n t o f therapist contact t i m e f o r patients i n cognitive
t h e r a p y i n i t s e l f is i n s u f f i c i e n t t o a c c o u n t f o r t h e g r e a t e r efficacy o f
cognitive therapy i n symptomatic relief.
I n g e n e r a l , p s y c h o t h e r a p y o u t c o m e studies o f b o t h d e p r e s s e d
s t u d e n t s a n d p s y c h i a t r i c o u t p a t i e n t p o p u l a t i o n s have s h o w n t h a t c o g n i -
t i v e t h e r a p y is m o r e e f f e c t i v e t h a n w a i t i n g - l i s t a n d o t h e r a c t i v e -
t r e a t m e n t c o n t r o l s , i n c l u d i n g p h a r m a c o t h e r a p y (the m o s t e f f e c t i v e
t r e a t m e n t k n o w n t o d a t e f o r t h e depressive s y n d r o m e ) . S e c o n d l y , t h e
p o t e n t i a l p r o p h y l a c t i c v a l u e o f c o g n i t i v e t h e r a p y is i m p l i e d by
p r e l i m i n a r y f o l l o w - u p d a t a . T h e s e f i n d i n g s are consistent w i t h t h e n o -
t i o n t h a t c o g n i t i o n s a n d schemas p l a y a m a j o r r o l e i n t h e i n d u c t i o n o r
maintenance o f depression. A d d i t i o n a l studies are n e e d e d to i d e n t i f y
t h e p r e d i c t o r s o f r e s p o n s e t o t h i s t r e a t m e n t a n d to d e t e r m i n e t h e a p -
p l i c a b i l i t y o f this p s y c h o t h e r a p y t o o t h e r p o p u l a t i o n s .

SUMMARY
T h e c o g n i t i v e t h e o r y o f d e p r e s s i o n o f f e r s a testable set o f h y p o t h e s e s
t o e x p l a i n t h e s y m p t o m a t o l o g y a n d t h e p r e d i s p o s i t i o n o f relapse i n
p a t i e n t s w i t h t h e depressive s y n d r o m e . T h e c o g n i t i v e t r i a d ( n e g a t i v e
views o f self, f u t u r e , a n d w o r l d ) , specific t h i n k i n g e r r o r s d e f i c i e n t i n
l o g i c , a n d t h e existence o f h y p e r v a l e n t schemas f o r m t h e c o r n e r s t o n e s o f
this m o d e l .
T h i s c o g n i t i v e t h e o r y is t h e basis f o r a specific p s y c h o t h e r a p y f o r
d e p r e s s i o n — c o g n i t i v e t h e r a p y . T h i s t r e a t m e n t consists o f a n u m b e r o f
t e c h n i q u e s , a few o f w h i c h are d e s c r i b e d a n d i l l u s t r a t e d above. Seven
c o n t r o l l e d o u t c o m e studies i n d e p r e s s e d s t u d e n t s o r p s y c h i a t r i c o u t -
p a t i e n t s s h o w c o g n i t i v e t h e r a p y t o e x c e e d t h e efficacy o f w a i t i n g - l i s t ,
nondirective, supportive a n d behavioral-therapy controls. O u r recent
s t u d y i n m o d e r a t e - s e v e r e l y d e p r e s s e d o u t p a t i e n t s shows t h a t c o g n i t i v e
t h e r a p y was m o r e e f f e c t i v e t h a n i m i p r a m i n e h y d r o c h l o r i d e i n p r o v i d i n g
acute s y m p t o m a t i c r e l i e f a n d i n d e c r e a s i n g p r e m a t u r e d r o p o u t s f r o m
218 A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

treatment. A d d i t i o n a l studies o f t h e acute a n d p r o p h y l a c t i c effects o f

t h i s p s y c h o t h e r a p y are i n d i c a t e d .

Acknowledgements: T h e a u t h o r s w i s h to e x p r e s s s i n c e r e a p p r e c i a t i o n to M s . J o s e p h i n e R a h n
for h e r assistance i n t y p i n g the m a n u s c r i p t , a n d M s . C h a r l o t t e H a r d y , M . S . W . f o r h e r e d i -
torial assistance.
T h i s w o r k w a s s u p p o r t e d i n p a r t by U . S . P u b l i c H e a l t h S e r v i c e g r a n t s MH-28459-02
(A.J.R.) and MH-19989-06 (A.T.B.).

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C l i n i c , R m . 5 1 9 , 133 S . 3 6 St. P h i l a d e l p h i a , P a . 1 9 1 0 4 )
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Cognitive Therapy andR esearch, 1:59, 1977.
10. Gioe, V . J . C o g n i t i v e M o d i f i c a t i o n a n d Positive G r o u p E x p e r i e n c e as a T r e a t m e n t for
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m e n t o f D e p r e s s i o n . J . Clin. Consult. Psychol., 45:543, 1977.
12. Morris, N. E . A G r o u p S e l f - I n s t r u c t i o n M e t h o d for t h e T r e a t m e n t o f D e p r e s s e d O u t -
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