Depression is one of the most common reasons for medical office visit, and is the most common reason for which people seek or are referred for psychological or psychiatric treatment. The iconic image of the psychiatric consultation in our culture is the patient reclining on the therapist's couch, talking for 50 minutes at a time about problems, emotions, conflicts and complexes. In fact, the psychiatric treatment of depression today is usually within a medical paradigm, with a clinical interview and mental status examination leading to a specific diagnosis and then to the prescription of one or more antidepressant or other medications. For many people this has represented a significant improvement, and is certainly faster and less expensive than the long courses of psychotherapy and psychoanalysis that were the norm a generation or two ago. There are still many people, however, who do not want to take prescription drugs for depression or other mental and emotional symptoms, who cannot tolerate them for one reason or another or who have taken them with little or no benefit. Psychotherapy still has a role to play in making these people feel and function better, and cognitive behavioral therapy (CBT) is one of the most effective and efficient techniques.
CBT is a combination of cognitive therapy and behavioral therapy. Cognitive therapy was developed by psychologist Albert Ellis and psychiatrist Aaron Beck during the 1950s and 1960s, and is based upon the cognitive model of behavior, which holds that thoughts, feelings and behavior are connected, and that inaccurate thinking, distressing feelings and unhelpful behavior can be identified, analyzed and changed to help people overcome difficulties. This is done by working collaboratively with a therapist to identify patterns of thinking that are distorted or incorrect and to test and modify beliefs about people and situations. The therapist helps the patient or client identify errors or distortions of thinking about situations and people that can lead to incorrect beliefs about them and inappropriate behaviors in response to those beliefs. Behavioral therapy is descended from some ancient philosophical traditions, but took modern form in the ideas of Edward Thorndike, who coined the term "behavior modification" in 1911, and B.F. Skinner and his school, who showed that almost any kind of behavior could be changed with repeated practice. CBT uses cognitive techniques to identify thoughts and feelings that cause distress and when acted upon can cause problematic behavior, and helps people think about them differently, as well as behavioral methods to train people in different and more effective ways to respond to difficult situations. The method can thus help to change moods and thoughts which are distressing and to change behavioral actions based on these moods and thoughts that can cause problems.
There are several different techniques for CBT. Brief CBT is designed to be carried out in several sessions totaling 12 hours or less, and is intended to deal with crises. This is particularly helpful in military situations, during medical hospitalizations and for the prevention of threatening suicide. Cognitive emotional behavioral therapy is a more extended version of CBT, developed first for eating disorder patients but now used for many other conditions: patients or clients learn to evaluate why they experience distress and to reduce the need for dysfunctional behaviors like starving, binging, purging and abusing substances. It is sometimes used as a "pretreatment" regimen for depression, anxiety and obsessions or compulsions. Most people take part in structured CBT, in which thoughts and feelings are analyzed, alternative behaviors in response to these thoughts and feelings are then identified and replacing the old problem behaviors with new and more effective ones is finally practiced. This is designed to get individuals to specific goals within a specific period of time.
There are many controlled trials in which the effectiveness of CBT is compared to some other treatment for depression or to the condition of treated patients before they began CBT. These have usually demonstrated a significant difference with CBT, and have not shown the incidence of side effects and treatment discontinuation that the various antidepressant medications have, even though drug treatment is effective, too. CBT compares favorably in effectiveness and cost to most other techniques of psychotherapy, particularly the traditional forms of psychoanalysis. CBT is usually done with benefit in face-to-face sessions with a therapist, but can be done by telephone and computer with demonstrable benefit. No significant side effects or problems have been identified with CBT. The practice guidelines for depression treatment issued in 2010 by the American Psychiatric Association classify CBT as a first-line psychotherapy technique that is effective and safe.
The many new medications that have been developed for the treatment of depression have been very helpful for many people. Those who do not wish to go down that road may very well be helped by the newer techniques of talking therapy, which do not involve prolonged periods of analysis and may not even need a therapist's couch. Cognitive behavioral therapy is safe and has been proven to be effective in many situations, including depression.
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