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Cognitive Behavioural Therapy
Zindel Segal


Zindel Segal, MD
Head, Cognitive Behavioural Therapy Unit
Clarke Institute of Psychiatry, and
Head, Psychotherapy Research
Department of Psychiatry
University of Toronto Psychotherapy Program

 
q What exactly is cognitive behavioural therapy?
a Cognitive therapy is a form of psychotherapy or psychological treatment that tries to teach patients how to recognize the connection between their specific thoughts and the effects that thinking has on their emotions.
   
q Was it developed many years ago, and has the therapy evolved over the course of the years in terms of how it is now applied?

a Cognitive therapy has a fairly recent history - it is about 30 years old - and it's been used in a number of different disorders. There have been some modifications recently, one of which is a greater emphasis on the therapeutic relationship between the patient and the therapist so that the patient understands the reasons for doing some of the tasks that are involved in cognitive therapy. There has also been a greater emphasis on the role of the patient's emotional reactions and how cognitive therapy can help people understand those reactions.
   
q Where do you find cognitive behavioral therapy most useful?
a The evidence for cognitive therapy indicates that it is very helpful for patients who have recurrent major depressive disorder, unipolar type, while panic disorder and social phobia have also been found to be very responsive to cognitive therapy. There is also some very early evidence suggesting that cognitive therapy can be very helpful for patients with bipolar disorder when used as an adjunct to mood stabilizing pharmacotherapy.
   
q Can you give us an example of how you would approach, for example, a patient who is depressed and how you would use this treatment for depression?

a Depression presents with a couple of problems, one of which is that people often withdraw from activities, and in a sense shut out the world. Another problem with depression is that patients are often very self-critical and have hopeless thoughts that can take the motivation away from patients to want to change their situation. So in cognitive therapy, we try to address both of these problems. The first thing we try and get people to do is examine what activities they are performing and which activities they may have stopped performing or things that have fallen off from their usual schedule, and then work with them to increase the behaviours that they used to enjoy doing. So, for example, people may have stopped exercising, they've stopped going for walks, they stay in bed all day. So we try and get people to focus on those behaviours and to do a little bit more for themselves. The other thing we do is try to get people to look at their thoughts as to why they are staying in bed, or why they are not exercising or why they are not going for walks. Very often what we find is, that people are saying to themselves, "It's not going to help; it's not going to make any difference", and as a result, they simply give up. In cognitive therapy, we try to get people to treat those thoughts as hypotheses, as ideas that can be tested to see whether they are true or not. We might ask someone to exercise, for example. But before they go exercise, or before they go shopping or go for a walk, we have them write out their ideas about what this is going to do for their mood. Typically they won't feel this is going to change their mood or help them in any way. And then we ask them to go do the activity and when they get back, rate their mood again, and also to tell us if the activity had the effect that they thought it would. Often, people will see that their ideas or predictions weren't accurate, that they feel a bit better having done the activity or that it wasn't as bad as they thought it might be.
   
q Can you give me an idea of the kind of negative thinking that a depressed patient might have which serves to perpetuate or perhaps even trigger depression?

a There is a lot of good research that shows that patients who are depressed tend to think of themselves in very negative ways. They are very critical of themselves. They may feel that they are worthless, that no one really wants them around, that people are judging them and rejecting them, that their situation is hopeless, that things are never going to change. These thoughts are very typical thoughts in depression and I often tell my patients that these kinds of thoughts are a form of depressive propaganda and that when they start to think this way, they need to recognize that these thoughts are part of the depression. In panic disorder, a very common anxiety problem, thoughts have more to do with a person feeling that if they start to feel anxious, this is very dangerous, they can't handle the symptoms, they are going to pass out, they are going to suffocate, they are going to die, they need to get out of the place as quickly as possible. Again, these are ways of thinking about themselves that are fueled by the anxiety. And I say to patients that this is an example of the anxiety talking to them. Both of these types of thoughts in depression and anxiety are very common, and one of the first things we do in cognitive therapy is help patients recognize the fact that they are saying things to themselves, especially in situations when they feel very sad or when they feel very anxious, and that these thoughts can contribute to maintaining their feelings.
   
q Are patients who think very negatively about themselves resistant or reluctant to acknowledge to themselves that they have a certain hand in perpetuating their mood disorder?

a We try not to talk about who is to blame for the depression. It's not clear what causes depression, and I think until we know that, it is really hard to say that depression is the patient's fault or it's occurred because of certain things the patient did. It may very well be that that's not the case but rather, that depression is only associated with these negative thoughts. We try and explain that patients can do something about their depression, and learning cognitive therapy provides them with a set of tools for responding to these negative thoughts. If you are going around telling yourself that you're unattractive; that you do not have any chance of meeting people, or that you are always going to be a failure, or that you are a loser, or that people don't want you, belief in those thoughts will make you try to do far less for yourself than having other thoughts, such as you may have had some setbacks but you've also had some successes and that continuing to do things for yourself will eventually pay off. The cognitive therapy approach really tries to give people a chance to learn some tools so they can respond to those thoughts so that people aren't always being victimized by the same depressive propaganda.
   
q Is there a step-by-step plan that you apply when you are using this therapy or is it more intuitive?

a There is a step-by-step plan. There are a number of excellent therapy books and patient manuals that we use. Right now, I really favour the book by [Dennis] Greenberger and [Christine] Padesky called Mind Over Mood [Change How You Feel by Changing the Way You Think. The Guilford Press. New York. 1995]. This is the patient manual we use in our clinic. And it's also very helpful for patients because it lays out the ideas behind cognitive therapy in a clear, understandable way, and also breaks down the steps involved so that people can see that as they learn more about cognitive therapy, they can progress through different tasks.
   
q What kind of success rates are you getting with your patients?
a Our success rates are fairly typical and can be compared to the success rates reported in many of the controlled studies that have evaluated cognitive therapy and pharmacotherapy. The success rates for the treatment of depression I think are in the range of 60 to 75%; for the treatment of panic disorder they are a little bit higher, within the range of 65 to 80%. Of course, that means there are still some patients for whom cognitive therapy may not be effective. There are also some patients who may decide that they don't really want to learn about the things that are required of them in cognitive therapy or they don't really want to perform tasks or go through the exercises. But I would say that for the most part, the good news is that the majority of people that we've seen tend to benefit from cognitive therapy once they've been through the course of treatment.
   
q Do you use cognitive behavioural therapy in addition to antidepressants in the treatment of anxiety or depression?

a Our experience has been that patients can benefit whether they are on antidepressant medication or other forms of pharmacotherapy so, cognitive therapy is compatible with the use of medication given at the same time. What we have found to be very important, however, is the need to be clear with patients about how these two treatments can work together to help their condition improve.
   
q Can you give me an idea as to how cognitive therapy, which is a psychological tool, could improve mood when there is no alteration in biochemistry? Or is there an alteration in biochemistry?

a That's a good question. I think that there have been a number of studies which have shown that if people learn new behaviours, new ways of thinking, and these new behaviours and thoughts can reduce their level of stress, this can lead to other physiological changes in body. Right now, my best understanding of what causes depression is that there are a number of factors that are involved and there are number of reasons for depression, and there may be a number of ways in which depression can be alleviated. Pharmacotherapy is certainly very effective, but cognitive therapy has been shown to be equally effective, and it might be that they are going through different doors to get to the same place, and once they are at that place, they can both reduce symptoms of depression.
   
q Which types of patients are likely to respond to cognitive therapy? Are they identifiable?

a We have found that patients who have a willingness to engage in certain homework assignments or who will work for themselves will benefit from cognitive therapy. Patients who have "double depression" for example - dysthymia super-imposed on a major episode of depression - may not do as well in cognitive therapy. But I have to say that the form of treatment I'm speaking of is relatively short-term, where typically, people get between 15 to 20 sessions of therapy. It's possible that patients who need a longer course of treatment may benefit from longer courses of cognitive therapy.
   
q What about interpersonal therapy? Does it have a role in mood disorders, and how does it differ from cognitive therapy?

a Interpersonal therapy has been shown to be very effective in the treatment of major depression. It differs from cognitive therapy in the sense that it does not focus as much on the patient's thoughts and feelings and getting people to understand the role that their thinking may play. Instead, interpersonal therapy looks at changes in the person's environment - their social circumstances. Has the person suffered a loss recently? Has the person changed their role from, let's say, being a worker to an unemployed worker, or a wife to a widow? Have there been people who have left the person's life? These are the kinds of things that get emphasized in interpersonal therapy and once again, it seems there are a number of ways to reduce the symptoms of depression and interpersonal therapy might be another one of those.
   
q Is interpersonal therapy used for anxiety disorders?
a No, not that I know of.
   
q What does it take to be a good behavioural therapist?
a To be a good cognitive behavioural therapist, the skills are not that different from what it takes to be a good therapist in general. You need to be able to listen to a patient's story, you need to be able to understand the circumstances that are preventing patients from living the kind of life that they want, and I think you also have to be willing to work collaboratively with your patient so that if you are going to ask them to do things, to ask patients themselves if there are specific activities that they would like to see themselves perform again. There are technical factors that involve training in cognitive therapy but there are non-technical factors too which I think have to do with knowing how to listen to people, and being willing to work with people to help them pull out of a very difficult emotional problem.
   

 

 

 

 


Over one million Canadians suffer from some form of depressive illness.