Clinical Depression is so widespread that it has been called 'the common cold of psychiatry’. One in every five woman in New Zealand will develop a depressive disorder at some stage during their lifetime – a lifetime prevalence of 19.4% for females, compared with 10% for males (Wells et al, 1989). Between 20%-25% of people with a major depressive disorder are likely to contemplate or attempt suicide. (The Core Debater, Feb 1995)

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), Major Depressive Episode is characterised as follows. There is either depressed mood or a loss of interest or pleasure in daily activities which represents a change from the person’s normal mood; social, occupational, educational or other important functioning is negatively impaired; and at least four of the following are present: significant weight loss or gain, decrease or increase in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, indecisiveness, recurrent thoughts of death, and suicidal ideation.

Cognitive-behavioural theory comes from a variety of sources, the two main streams being 'Rational Emotive Behaviour Therapy’ (REBT) developed by Albert Ellis; and Aaron Beck’s 'Cognitive Therapy’ (CT).

From a cognitive-behavioural point of view, the essential component of depression is a negative cognitive set: a tendency to view the self, future and the world in a dysfunctional, negative manner, which Beck (1967) has termed the 'negative triad’. The major symptoms of a depressive disorder, affective, behavioural, somatic and motivational, are viewed as a direct consequence of the negative thinking pattern.

Experience leads people to form assumptions about themselves and the world which are then used to perceive, govern and evaluate behaviour. The need to predict and make sense of one’s experience is vital for normal functioning, but some assumptions are rigid, extreme, resistant to change and thus counter productive. It is important to note that these assumptions alone do not account for the development of clinical depression. Problems develop when critical incidents (activating events) occur which mesh with aspects of an individual’s personal system of beliefs. For example, a belief that 'to be loved is essential to happiness’ could lead to depression if triggered by rejection. Once activated, dysfunctional assumptions produce an upsurge of 'negative automatic thoughts’ leading to depressive symptoms. eg. withdrawal, loss of interest, anxiety, guilt etc. As depression develops, negative automatic thoughts become increasingly frequent and intense and more rational thoughts are crowded out.

Note that according to the cognitive model, negative thinking does not cause depression – it is part of it. Also, there is no qualitative difference between the thinking processes of most depressed people and the thinking processes of euthymic people; rather depression exaggerates and intensifies processes present in all of us.

The turmoil of depression is experienced by both sexes. Irrational beliefs are not the sole province of one gender; why, then, is it that depressed women greatly outnumber men?

Humans move easily from being critical of their behaviour to condemning themselves, but the particular way in which we creatively 'do ourselves in’ may be partly related to the culture in which we live. The societal environment of females is not equivalent to the societal environment of males. Blechman, 1984, states that 'The world tends to treat a woman differently from a man, even when the two have similar capabilities…’

In research studies where actual competence levels between men and women did not differ, women were nonetheless more likely to assume that they did poorly, to condemn themselves as incompetent and to feel more dysphoric as a result (Walen 1998). So, while the quality of self-rating beliefs is not unique to women, their frequency of occurrence and intransigence to removal may be greater in women by virtue of their social experiences. 'Women are socialised to attribute success to luck and failure to lack of ability. In contrast men attribute success to ability and failure to bad luck’ (Beckham, 1995).

Nearly all women with depression would experience passive suicidal ideation at some stage during their illness. 80% of all suicides can be related to depression. Women are three to four times more likely to make suicide attempts than men (though men are more likely than women to complete suicide). Major depression is the psychiatric diagnosis most commonly associated with suicide. According to Shuchter (1996) 'The best protection against suicide is the effective treatment of the depression’. Suicide contemplation results from certain dysfunctional beliefs and attitudes:

Cognitive behaviour therapy is an active, directive, structured, psychoeducational approach based on the cognitive-behavioural theory of causation: 'Men are disturbed not by things but by the views they take of them’ (Epictetus, 1^st Century A.D.). There are three main assumptions underlying CBT: (1) emotions and behaviours are determined by thinking; (2) emotional disorders result from negative and unrealistic thinking; and (3) by altering this negative and unrealistic thinking, emotional disturbances can be reduced. The process of CBT involves teaching the client to:

• monitor emotional upsets and activating events;
• identify maladaptive thinking and beliefs;
• realise the connections between thinking, emotions and behaviour;
• test out maladaptive thinking and beliefs by examining the evidence for and against them;
• substitute the negative thinking with more realistic thinking.

(Trower and Casey, 1988)

The major goal of most feminist therapists is to aid the client in making the transition from (1) the childlike, helpless, submissive person she was socialised to be; to (2) an autonomous person with personal strength, independence and trust in herself and other women. Janet Wolfe (1975) believes there is no therapy which better suits the requirements of a truly feminist approach than cognitive-behaviour therapy – because CBT encourages autonomy, self development, and positive feelings about oneself; helps to re-channel rage, minimises the power differential between therapist and client, and provides in the therapist a healthy role model. Wolfe and others have described some typical irrational, self-defeating beliefs that are most relevant to women:

• Love slobbism: the belief that love should be their whole existence and not just a part of it. For example, a woman may tell herself about rejection: "It’s awful that I have been rejected. I should have been more witty, beautiful, loving and then he would not have rejected me"; or: "If I fail in this relationship, I am an undesirable, helpless reject and will never be able to have any successful relationships."
• Assertive difficulties. Jane, a client of mine, said to me: "I would hurt my Mum’s feelings and would be an uncaring daughter if I didn’t do … for her." The sex role socialisation message is: 'Women are expected to take care of others and to feel guilty when they put their own interests first.’ A rational counter–message to this could be: 'How does making my interests as important as someone else’s turn me into a bad person?’ As well as helping women to challenge irrational beliefs, especially in the area of sex-role socialisation messages, it is also very useful to help them role-play possible assertive responses to situations where women find it difficult to assert themselves.
• Guilt and self blame. Wolfe points out that women tend to damn themselves when they act in a stereotypical fashion and behave passively; and also damn themselves when they depart from traditional role behaviour by acting assertively or aggressively.
• Low frustration tolerance is characterised by beliefs that it is awful not to get what you want and awful to be criticised. The 'Cinderella myth’ may represent an example of LFT: 'If I am good and do all the right things then one day my life will magically change’.
• Re-channelling hostility and rage. When women become aware of ways in which society and men in particular have oppressed them there is often a flood of long pent-up rage. The CBT therapist can help women make a distinction between damning a persons behaviour and damning that person as a whole.

Janet Wolfe (1995) believes that a large number of the 'shoulds’ that underlie a womans irrational beliefs are fed from the deep well of sex-role socialisation shoulds, e.g. 'I must be married and have kids in order to be normal and fulfilled’.

We began the assessment phase with Jane’s perception of what was wrong with her and her thoughts about being diagnosed with clinical depression. Then we examined the following aspects:

Next, I introduced Jane to the concept of CBT as a treatment method. She appeared receptive to the idea of rational and irrational thoughts and recognised their relevance to her own experiences. We talked about the equal, collaborative relationship that this form of therapy requires. She reiterated that she likes to feel in control and agreed to work with me rather than expect me to 'cure’ her.

We talked about the length and frequency of the sessions, agreeing initially to meet for one hour twice-weekly, reducing to weekly sessions once her distress and depressive symptoms began to lessen.

I also talked with Jane about the importance of setting the agenda for each session, and we agreed that as part of our agenda each session we would:

At every contact I had with Jane I would take particular care to prioritise dealing with her feelings of hopelessness, suicidal ideation and negative expectations of treatment.

During our assessment session Jane had admitted to continuing thoughts of suicide. She talked about her recent suicide attempt where she had overdosed on a supply of medication she found in their medicine cabinet. She sought help immediately afterward by phoning her husband Craig and informing him of what she had done.

Jane said "I think that overdose was really my way of saying – look, you’re not getting it. Something is really wrong. I was hoping it would make them stand back and think – gosh something is really wrong with Jane. She is really ill, she needs help."

Jane and I came to the conclusion that her motivation for the suicide attempt was the 'desire to communicate’ referred to earlier. At this stage we explored what she had been trying to communicate to Craig and her family over the past few months. Jane reported that she had been feeling guilty about being so low but had not talked openly to her family about this. She said that up to now she had felt that being depressed was just a matter of someone not 'pulling their socks up.’ Recognising Jane’s 'communication’ motivation, we brain-stormed ways other than suicide of effectively getting across to her family how she was feeling.

Another priority at this stage was to develop a 'Personal Self Harm Management Plan’ with Jane and Craig. This constituted a written list covering the following items:

• In the event of suicidal feelings or thoughts, Jane would do one or more of the following: write down and analyse her thoughts of self-harm; walk round the block, with the children if necessary; exercise to a fitness video; walk around the park; go for a run; call and talk with a friend or someone else (names and phone numbers were listed); and/or do something that was usually enjoyable (these items were listed), even if it did not seem so at present
• If feelings of self-harm persisted, Jane would make contact with a source of professional help (listed along with phone numbers), including myself, her doctor, psychiatric emergency service, telephone counselling service, etc.

Another technique I used with Jane at this time was the 'ABC Diary’. She recorded situations when she felt suicidal (Activating events); what she was thinking (her Beliefs about the activating events) and how she was feeling or what she did (her emotional and behavioural Consequences). She was to bring this diary to each session for review and discussion.

With regard to assessing Jane’s level of self-harm risk, I considered a number of factors as well as the 'communication’ motivation described earlier. On the negative side (1) she felt guilty; and (2) had a hopeless view of the future. On the positive side: (1) there was no family history of suicide or mental illness; (2) she was happy for Craig to be involved in her treatment; (3) she had current suicidal thoughts but no plan.

My assessment at this stage suggested that Jane was relatively 'safe’ to remain at home and for treatment to continue on an outpatient basis. If I had felt that Jane was 'not safe’ I would have asked for a psychiatrist review (and if needed, utilised the Mental Health Act for this to be carried out). Jane and Craig were both aware that hospitalisation and possibly the Mental Health Act were an option should Jane’s condition worsen.

At this time Jane and Craig were pondering the issue of antidepressant medication. I encouraged them to write down, from their point of view, the advantages and disadvantages of medication. This resulted in the following list:

• Advantages: My GP and the psychiatrist recommend medication; studies show that the combination of CBT and medication is the most effective treatment – more effective than either treatment alone..
• Disadvantages: I am afraid of becoming physically addicted to the medication; I might feel 'drugged up’; might rely on the pills to get through the bad patches; might have bad side effects resulting in further disability; it is a 'failure’ to rely on medication I should be able to get through this without pills.

One of Jane’s initial concerns was the fact that she 'wasn’t getting anything done’ and found it very difficult to cope with the demands of daily living: "I don’t want to do anything. I can’t do anything. I just can’t get motivated."

I explained to Jane that I would help her plan how she would spend her time between our sessions. I asked her to begin by monitoring her activities, documenting them on an hourly basis and rating each activity 0-10 for pleasure and for mastery.

Once she had completed her activity record, we were able to see where there was scope for Jane to modify her daily schedule to make it more active and satisfying. The next step, therefore, was to turn the 'activity record’ into an 'activity schedule’, where each day was planned in advance on an hourly basis. Jane would continue to rate each activity for pleasure and mastery. This was designed to achieve two goals: (1) to gradually increase Janes activity level and to maximise her mastery and pleasure, and (2) to help Jane see that she was gradually achieving more and increasing the amount of pleasure she got from her activities (depressed people often find it hard, in the early stages of treatment, to acknowledge they are improving – recording hour-by-hour changes can provide 'documentary evidence’).

I talked to Jane about the importance of doing things before she feels like doing them, and that she doesn’t have to do anything to a high standard – she just has to do it.

We also talked about the therapeutic value of physical exercise. Jane had, in the past, been an enthusiastic runner but this was the first activity that disappeared as her mood dropped. She explained that she used to run early in the morning before the children got up, but she now felt so 'terrible’ in the mornings that going for a run would be impossible. When we explored this idea further, Jane agreed that the evidence indicated physical activity has a positive effect on depression. She agreed to start running again, but thought she would be more successful if she ran in the early evening once her children were in bed, as her mood generally lifted toward the end of the day.

During our treatment sessions Jane talked about constantly worrying: "I worry about my illness and the effect on my family all day. The thoughts go round and round in my head all the time."

Before long we began to address Jane’s belief, identified earlier, that she should always put others before herself. "I was brought up that way. Mum always put us kids first – she never did anything for herself." The core belief that we uncovered was: "It is selfish to put my own wants before those of others."

I showed Jane how to dispute this belief, using the pragmatic, logical and empirical strategies outlined by Kopec et al (1994). Jane developed a new rational belief: "Time for myself is just as important as time for anyone else."

To help Jane develop a philosophical foundation for this new belief, I introduced her to the concept of 'enlightened self-interest’ (Froggatt, 1993). This concept is based on the principle of looking after one’s own interests, while taking into account the interests of those around

A central feature of CBT is self help work. This is the work done by the client between therapy sessions and is a key reason why CBT is so effective and efficient in achieving deep and lasting change in a short period of time. Over the time we worked together, Jane carried out the following homework assignments:

1. Educative homework: reading articles and watching educational videos on depression.
2. Cognitive homework: two column notebook, listing irrational thoughts and rational alternatives; rational self analysis (Froggatt, 1993) involving self-administration of the ABC analysis model; listening to tape-recordings of therapy sessions; and rational cards containing an old irrational belief with a new rational alternative, that Jane would read 8-10 times each day for 2-3 weeks.
3. Behavioural homework: shame attacking – when Jane’s mood had lifted, we designed a shame attack in which she went to the shops wearing odd shoes, on in order to confront her overconcern about how other people viewed her; paradoxical behaviour – to help Jane challenge her perfectionistic tendencies, we designed a 'stepping out of character’ homework activity in which she did not complete a task to her usual 'perfect’ standard.

Development of homework assignments followed some general principles:

I prepared Jane from the outset for the end of therapy by discussing the likely time scale and number of sessions involved. As her condition improved we gradually reduced our sessions to weekly, fortnightly and then monthly.

As part of my evaluation of the effectiveness of our therapy I clarified with Jane whether improvements in her mental state were due to internal changes in her dysfunctional thinking (which would enable her to manage her moods in the long-term) or simply due to fortuitous changes in her external circumstances. Signs that she had made effective changes in her dysfunctional thinking were:

• Jane was able to set herself appropriate homework assignments.
• She was able to effectively use rational self-analysis.
• She reported increased motivation levels and feeling 'happy’.
• She was less tearful, and was able to plan and carry out tasks.
• Her family reported that she was 'back to normal’.
• There was increased quality of interaction with her children.
• She reported reduced irritability.
• She was able to acknowledge where she had been and where she was now.

We discussed the fact that depression can reoccur and devised a self help plan. We identified Jane’s early warning signs of relapse: increased tearfulness, lack of confidence in being able to cope, sleep disturbance, increased negative and irrational thoughts, increased irritability toward the children and worrying thoughts. Preventive strategies Jane would put into place included:

• Keep a two-column notebook whenever she identified any key symptoms.
• Rational self analysis.
• Re-reading self-help literature she had previously found helpful.
• Tell friends and family how she was feeling.
• Increase self-nurturing activities, rest and relaxation.
• If the above strategies were not effective within one to two weeks or if suicidal thoughts returned, contact a health professional.

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