Cognitive Therapy for Depression: How to Get Started

Gloomy thinking is a common, painful symptom of depression. Our minds get flooded with negative thoughts about ourselves, about other people, about the world around us, about the future. Depression imposes a pessimistic filter on our minds.

If we want to get depression under control, we need to take steps to quash these negative thoughts. We need to break this pessimistic filter. The alternative is not false optimism, pretending life is wonderful and carefree. The alternative is just a more reasonable, balanced way of thinking that acknowledges our strengths and possibilities.

Cognitive therapy is an effective treatment for depression which targets negative thinking. Cognitive therapy is basically a process of recognizing the negative, pessimistic, self-loathing thought patterns typical of depression; challenging those negative thoughts, examining and questioning them, seeing how distorted they are; and replacing them with more realistic and positive ways of thinking. With time and practice, this process can become an ingrained mental habit.


The History of Cognitive Therapy

The field of cognitive therapy grew up in the 1960s and 1970s as an alternative to traditional psychoanalytic or talk-therapy approaches. The generally acknowledged godfather of the field is Aaron Beck, who wrote early groundbreaking books like Depression: Causes and Treatment (1972) and Cognitive Therapy and the Emotional Disorders (1975). Beck’s nine-page 1997 essay “The past and future of cognitive therapy” is a good place to start for anyone interested in this history.

Beck traced depression and other mood disorders to what he called “automatic thoughts”. (Later writers expand this to “automatic negative thoughts”.) He developed cognitive therapy as a way of helping patients to recognize and change self-destructive automatic thoughts.

Emotional reactions, movitations and overt behavior are guided by thinking. A person may not be fully aware of the automatic thoughts that influence to a large extent how he acts, what he feels, and how much he enjoys his experiences. With some training, however, he may increase his awareness of these thoughts and learn to pinpoint them with a high degree of regularity. It is possible to perceive a thought, focus on it, and evaluate it just as one can identify and reflect on a sensation (such as pain) or an external stimulus (such as a verbal statement).

The term “maladaptive thoughts” is applied to ideation that interferes with the ability to cope with life experiences, unnecessarily disrupts internal harmony, and produces inappropriate or excessive emotional reactions that are painful. In cognitive therapy, the patient focuses on those thoughts or images that produce unnecessary discomfort or suffering or lead to self-defeating behavior. (Cognitive Therapy and the Emotional Disorders, p 235)

The great popularizer of cognitive therapy for depression was David Burns, whose 1980 bestseller Feeling Good: The New Mood Therapy is still the single best book to read about beating depression. Here’s how Burns layed out the basic ideas behind cognitive therapy:

The first principle of cognitive therapy is that all your moods are created by your “cognitions” or thoughts. A cognition refers to the way you look at things — your perceptions, mental attitudes and beliefs. It includes the way you interpret things — what you say about something or someone to yourself. You feel the way you do right now because of the thoughts you are thinking at this moment. …

The second principle is that when you are feeling depressed, your thoughts are dominated by a pervasive negativity. You perceive not only yourself but the entire world in a dark, gloomy terms. What is even worse — you’ll come to believe things really are as bad as you imagine them to be. …

The third principle is … that the negative thoughts which cause your emotional turmoil nearly always contain gross distortions. Although these thoughts appear valid, you will learn that they are irrational or just plain wrong, and that twisted thinking is a major cause of your suffering. (Feeling Good, pp 12-13)

It’s an overstatement to say that “all your moods are created by your ‘cognitions'”. Depression has many causes. Nonetheless, perceptions, attitudes and beliefs can be powerful, especially when they remain unexamined and unchallenged.

Decades later, cognitive therapy remains one of the best treatments for depression. And there is strong empirical evidence that cognitive therapy really works.

The Basic Process

Cognitive therapy is a very pragmatic, problem-solving approach to depression. It does not emphasize dwelling on painful past experiences and gaining insight into the root causes of negative thinking. Instead, it emphasizes developing present-day strategies for changing negative thinking and alleviating the pain it causes.

At its core, cognitive therapy involves three steps:

1) Recognizing negative thoughts

We all have deeply ingrained ways of perceiving and making sense of our world. Aaron Beck used the term “automatic thoughts”, those that pop into our heads without much reflection. For depression sufferers, these automatic thoughts can become overwhelmingly pessimistic.

The first step is to become more aware of these automatic negative thoughts, to recognize and identify them as they happen. The best way to do this is to write them down.

These might be negative thoughts about yourself (“I’m a loser, I’m lazy, I’m such a screw-up”). They might be negative perceptions of your efforts — at work, in school, in relationships, in life — as a string of “failures”. They might be negative assumptions about what other people think of you. They might be pessimistic thoughts about your future prospects in life.

When you find yourself thinking this way, catch yourself, observe yourself thinking this way. Write down the negative thought as clearly as possible. This process can be painful at first. You might feel a strong resistance, a desire to push those negative thoughts back down below full consciousness. But remember that unexamined automatic thoughts remain persistent and powerful.

2) Challenging negative thoughts

The second step is where you start to fight back. By examining these automatic negative thoughts, by applying reason and commonsense, you can start to understand how irrational and unwarranted they are. By doing this, you can break down the power that negative thoughts hold over you.

Aaron Beck and David Burns both use the term “cognitive distortions” to describe the self-destructive thought patterns typical of depression. Another good term might be “logical flaws”. Beck and Burns believe that conscious awareness of these cognitive distortions can allow depression sufferers to challenge their negative thoughts.

David Burns in Feeling Good identifies several categories of “cognitive distortions” (chapter 3, “Understanding Your Moods”; pages 32-43).

  • All or Nothing Thinking — seeing anything short of perfection as a total failure
  • Overgeneralization — viewing one negative event as a never-ending pattern of defeat
  • Mental Filter — picking out one negative detail to obsess on
  • Discounting the Positive — insisting that positive experiences “don’t count”
  • Jumping to Conclusions: [a] Mind Reading — assuming that people are reacting negatively to you without evidence
  • Jumping to Conclusions: [b] Fortune Telling — predicting things will turn out badly
  • Magnification or Minimization — blow bad things way out of proportion, or downplaying good things inappropriately
  • Emotional Reasoning: reasoning from how you feel
  • Should Statements — criticizing yourself or other with “shoulds”, trying to motivate yourself with guilt and unreasonable expectations
  • Labeling — calling yourself things like “loser”, “lazy”, “fool”, “jerk”
  • Personalization: blaming yourself for something you’re not responsible for

Here’s a useful, printable chart (PDF) of Burns’ list. Other writers have made similar lists with different categories. Daniel Amen in Change Your Brain, Change Your Life adds “Always/Never Thinking”. A recent article by John Grohol lists 15 common cognitive distortions.

When you write down your own negative thoughts, try to figure out which cognitive distortions you’ve fallen for. Usually there will be more than one type of distortion. (There’s a lot of overlap between these categories, so don’t get bogged down in “is that overgeneralization or magnification?” decisions.)

Think of this process as a debate: your automatic negative thoughts telling you one thing, your conscious mind pointing out exactly how those thoughts are irrational, distorted, “just plain wrong”. Ideally you want to make this process of challenging negative thoughts by identifying the cognitive distortions into an ingrained mental habit.

3) Replacing negative thoughts

The third step is where you create a positive alternative to those automatic negative thoughts.

Once you have recognized a specific negative thought, and made yourself aware of how irrational that negative thought is, you want to formulate a more positive and rational response. Again, the best way to do this is to write it down.

Positive alternative thoughts do not have to be overly cheerful, Pollyannaish, irrationally exuberant. The rational alternative to “I fail at everything, I’m worthless” is not “I triumph at everything, I’m perfect”. Your positive responses to automatic negative thoughts should be reasonable, balanced, honest, compassionate. This process works best when your positive alternative is something you can believe on a gut level.

A positive alternative to “I fail at everything, I’m worthless” might be more like: “I fail at some things, I succeed at some things. Most of my efforts fall somewhere in the middle, like most people. If I think honestly, I can remember times when I succeeded and felt justifiably proud of my accomplishments. No one succeeds 100% of the time, and learning from mistakes is part of life.”

This example is intentionally vague. When you write down your automatic negative thoughts and positive rational responses, feel free to be as general or specific as you like.

David Burns recommends a “triple-column technique” for this exercise — automatic negative thought, cognitive distortion(s), positive rational response, written out side-by-side on a single sheet of paper. Here’s the simple printable worksheet I like to use:

cognitive therapy for depression worksheet

Getting Started

Cognitive therapy can work with or without a professional therapist. Some people start with regular weekly sessions with a therapist, then move to less frequent sessions once they feel confident with the process. Some people read about cognitive therapy and give it a try solo first, then maybe seek out a therapist.

The important thing is developing mental skills for battling negative thinking in your everyday life, not just when you’re in the therapist’s office or reading about the subject.

Regardless whether you have worked with a therapist in the past or plan to in the future, I highly recommend starting this recognize/challenge/replace process on your own. Better yet, start today. Don’t think “that sounds promising, I should try that sometime”, then gradually forget about it. Print out some three-column worksheets or open a notebook. Start to monitor your automatic negative thoughts. Pick one that seems particularly unreasonable and hurtful, write it down and get started.

This process can be very stressful at first. My advice: start today, but start slow. Don’t address more than one negative thought per day. Don’t spend more than 10-15 minutes on the exercise. When you’re finished, give yourself some credit — you pushed yourself to do something challenging, and you met the challenge. Give yourself a reward of some sort.

With practice and repetition, you might find that automatic negative thoughts lose their power over your mood. You might find yourself automatically thinking of how unreasonable those thoughts are, and automatically thinking about the rational positive response you wrote out last time that negative thought popped into your head.

Further recommended reading about cognitive therapy for depression: Feeling Good: The New Mood Therapy and The Feeling Good Handbook by David Burns.

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