Running head: COGNITIVE BEHAVIOR THERAPY 1

Cognitive Behavior Therapy in Depression Management

Students Name

Institution Affiliation
COGNITIVE BEHAVIOR THERAPY 2

Cognitive Behavior Therapy in Depression Management

Cognitive behavior theories refer to a set of strategies which can be used to identify and

explain the major reasons behind an individuals countenance as well as put across strategies that

can be used to help one improve their behaviors. This paper is an analysis of the cognitive

behavior therapy (CBT) with special attention being accorded to the case study of Karen. It aims

at identifying the causes of psychological disorders and the roles of the client and the counselor

in the therapy as well as highlighting the probable short term and long term goals of this medical

intervention. Consequently, this paper will provide an overview of the weaknesses and the

strengths of the model through the lens of Karens case. While analyzing Karens case study, I

will assume the role of a mentor health counselor.

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Conceptualization of How Psychological Problems Develop

Psychological problems are influenced by a range of factors that include an individuals

beliefs. Depression is one of the major psychological disorders that results when a person has

negative thoughts about himself or herself. Usually, one may feel depressed as a result of being

dejected close friends or even relatives. In the case study, Karen feels depressed since she

believes that her mother has abandoned and rejected her. Her relentless efforts to please her

mother (by excelling in academics) have also not borne any fruits, making Karen to feel

desperate and hopeless in life. Her unwillingness to wake up every morning signals that she has

become helpless; but unfortunately, she does not have the courage to share what she is going

through with her peers. Whenever individuals start having faulty misconceptions, for instance

about themselves or their families there is a higher probability that they might end up suffering

from depression. Individuals mode of thinking is directly related to the emotional reaction which

is reflected through his/her behaviors. This is the case with Karen who believes that her mother

has rejected her to an extent that she (her mother) has neglected her family duties. Eventually,

she becomes depressed and loses interest in some of the activities of daily living such as the

appetite for food and desire to dress decently. The signs and symptoms of depression are also

well brought out in the case as it is noted that Karen has become incapable of accomplishing her

usual roles such as handing in the assignment in time and even doing her editorial duties for the

schools newspapers.

The Cognitive Behavior Therapy

Cognitive behavior therapy (CBT) is considered as one of the most effective cognitive

approaches to overcoming depression and its related symptoms. Depression is defined as a

COGNITIVE BEHAVIOR THERAPY 4

mental condition that adversely affects ones potential to make rational decisions (National

Alliance of Mental Illnness, 2017). An individual suffering from depression has a very high

potential (an 85% probability rate) of relapsing, and if he/she does not seek adequate medical

care, such an occurrence might take a long time to heal and even recur (Sachsenweger, Fletcher

& Clarke 2016). People suffering from depression have to do with quite a number of challenges

such as decreased productivity as they are incapable of maintaining the required attention that

would enable them to carry out their duties as usual. Additionally, depressed people tend to

exhibit some signs of loneliness and would be seen spending time in isolation. Depression may

also have adverse effects on students as it leads to poor performance in academics. As a result,

some may drop out of school because of the embarrassment.

The cognitive behavior therapy (CBT) is a psychological intervention model that enables

one to recover from depression by re-evaluating irrational beliefs and distorted cognitive

functioning (Park-Taylor n.d). Karen, the seventeen-year-old lady in the case study, is no doubt

suffering from depression. The genesis of this mental condition can be traced back to the period

her family relocated to the United States and opted to retain their traditional Taiwanese family

practices. The continuous use of such practices implies that she could not adapt to the new

environment with ease (for example by creating new friends) and, hence, the reasons behind her

withdrawal symptoms. As noted by her teacher, though she was a bright student, she always

exhibited signs of social withdrawal which made her look sad at all times. Karens cause for

social withdrawal could be as a result of the frustration and the feeling that her mother had

rejected and abandoned her despite her effort to win her mothers attention through her

exemplary performance. Ellis proposes a theory that signals the occurrence of social withdrawal
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and points out that it has to be caused by an activating event which makes one to adopt a set of

beliefs that have far-reaching consequences on him/her.

This theory is referred to as the A-B-C sequence,

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Effective
Disput Philosop
ing hy

Figure 1: The A-B-C sequence model. Image retrieved from Australian Institute of Professional

Counsellors. (n.d.). Cognitive behavioral therapy: A guide to counseling therapies

(DVD). J & S Garrett Pty Ltd.

As illustrated in the model, recovery from depression involves various processes. One has

to first figure out the activating event that makes him/her prone to depression. Thereafter, one

has to dispute the irrational beliefs and in their place adopt the rational ones.

In the case study, the activating event would be the sudden change in her mothers

attitude towards her, which would mean that the mother will have to abandon her motherly and

wifely duties. Karen might have thought that she had wronged her mother and opted to work

hard in school so as to please her. She had to go through sleepless nights for the unappreciated

effort. However, the counselor would have to get to the bottom line of the causes of Karens

emotional actions, which may include the belief that a mother should always perform her wifely

duties such as taking care of the family and a mother must always give her children undivided

attention.
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As mentioned earlier, Sachsenweger, Fletcher & Clarke (2016) argued that an individual

suffering from depression has a very high potential of relapsing, something that is quite evident

in Karens case. Lately, she has been unable to discharge her duties as would be expected to the

extent that the class teacher has become concerned. She no longer hands in her assignments as

required and she has also missed several deadlines for submitting her drafts for printing in the

schools newspaper. The negative behaviors and thoughts an individual adopts as a result of

depression leads to withdrawal from activities that she/he would have been more interested in,

which leads to the relapse (Corey, 2009).. The conviction that she is different from her

classmates, which to her is the major reason why they behave in different manners, serves as the

main reason why Karen has suddenly lost interest in her editorial duties and academics. This is

reflected in her failure to hand in the assignments as expected. Karens depressive symptoms are

further escalated by her mothers decision to move back to Taiwan. This has caused a serious

disruption in her social life, her concentration in class has become dismal and she has also lost

her appetite for food. As a result of feeling rejected by her mother, it has also become impossible

for Karen to share her experiences with any of her friends.

Also, Karens family culture does not encourage one to talk about feelings, making it

impossible for her to share what she feels with her family members (her sister and her father).

Most of the patients suffering from depression also experience hopelessness in life as brought out

by Karen when she points out that she does not feel like waking up since she finds no reason to

do so. Also, depression among children can result from the detachment between the parents and

the siblings as it has happened in Karens case. Karen feels detached from her mother since she

feels that her mother has abandoned her. She also notes that the rejection by her mother has been

compounded by the inability of the mother to perform her duties as a mother and wife,
COGNITIVE BEHAVIOR THERAPY 7

prompting Karen to start putting more effort in her academics so as to catch her mothers

attention. Eventually, Karen started overworking herself and even experienced sleepless nights as

she thought of the best ways of drawing her mothers attention. This did not work and led to her

depression.

The therapy starts with the identification of the major causes of the depression. Before

this, the patients have to be keen while doing their activities of daily living. Since patients

depressive symptoms have a tendency of losing interest in their normal activities, it would be

important for a counselor to advise the patients to concentrate more on the positive thoughts and

feelings in order to be optimistic and check on the overpowering emotions. Additionally, it is

essential for the patients to avoid activities that will upset them and those that will make them

feel down-spirited. The patients are also encouraged to set short term and realistic goals,

avoiding the long term ones goals because they have higher potential to disappoint and frustrate

an individual if they are not achieved. The need for setting realistic goals is well brought out in

the case study by Karen when she desperately works hard in school to please her mother. This

definitely has a toll on her social behaviors as all her attention is directed towards achieving

academic excellence. The situation gets worse as her mother does not take any note despite her

improvement in academic performance. She becomes withdrawn and keeps to herself. In

addition, she also had to do with regular sleep disruptions.

CBT also encompasses encouraging the patients to restructure their thinking with an

objective of ensuring that they only think from a positive perspective. In such a scenario, patients

have to desist from any thoughts that might adversely affect their moods. With this in mind, the

therapist has to teach Karen how to overcome anger and this will eventually enable her to deal
COGNITIVE BEHAVIOR THERAPY 8

with the feeling of rejection and improve her moods. The resulting peace will help her to

overlook the opinions of the societal members on her family as she believes that her mothers

departure has tarnished the reputation of her family. Also, she will concentrate on her studies

more to make up for the time she lost while experiencing a relapse. To do this, Karen will be

made to understand that her education is her responsibility and not her mothers. Spending most

of her time by engaging in school duties will also enable her to effectively resume the role of

being the schools newspaper editor. This will provide a means to overcoming loneliness and

channel her energies on constructive activities. She will also achieve a sense of belonging at

school by working with her peers.

Additionally, the client will be instructed and directed on ways of changing her language.

The Rational emotive therapy (REBT) points out that individuals experience distorted cognitive

processes due to their use of imprecise language. As a counselor, I would advise Karen to

practice replacing the use of words such as ought to, absolute, and must by more preferred

words that do not imply finality. For instance, instead of saying that my mother should play her

role as expected, it would be better if she said it would be convenient that my mother plays her

role as expected. Teaching her how to cease using mandatory words (such as must and have to)

would be significant in helping her overcome helplessness and start reasoning from a more

positive perception. She will also be more receptive and tolerant to others by having moderate

expectations from herself and others.

Growth and Change

Corey (2009) is of the opinion that the successful implementation of the CBT takes the

form of growth and change approach between the patient and the counselor. According to Corey,
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a counselor might not be in a position to assist the client unless the two develop some form of

relationship that meets a number of conditions. Firstly, as the counselor, I recognize the need to

have psychological contact with Karen. However, there is a possibility that the two of us have a

difference since the client is considered to be in a state of incongruence and therefore vulnerable

to abuse while the therapist must be sensitive and empathetic to create an environment where the

client opens up and share information freely. At this point, patient confidentiality should be

adhered do and if need be the therapist should assure the client of the same.

The counselor must experience unconditional positive feelings for the client and some

empathy which he/she bases the treatment on. The relationship between the client and the

counselor is also based on an equality perspective. As the counselor allows the client to narrate

her ordeal and accepts her convictions, the client would also expect the counselor to reciprocate.

Additionally, the counselor will not be expected to withhold any important information from the

client or even try to complicate its acquisition. Since the client relies on this knowledge for

healing, it is only important that the counselor makes sure that its acquisition is relatively simple.

There is need on the part of the counselor to exhibit highest degree of professionalism while

working with the client. For example, this can be achieved if the client is made to understand that

her interests will be well catered for. The counselor should make a commitment to meet certain

reasonable obligations that pertain to helping the client and her confidante. If this happens, the

patient is more likely to open up and share all the information that might also help solve the

problem.

The Role of the Client and the Counselor

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For CBT to be effective, each of the partners must play their role as expected and with

openness and confidence. This means that the client and the counselor are in a trusting

therapeutic alliance. The importance of homework in the CBT is well document as it involves the

realization of the behavioral guidelines of operant and classical conditioning which assist the

client to adapt to a new environment (Sachsenweger, Fletcher & Clarke 2016). Homework is a

task that has to be accomplished by the patient during the therapy session with the sole aim of

enhancing a therapeutic effect and its discussion has to be in line with the agenda of the session

(Sachsenweger, Fletcher & Clarke, 2016). Sachsenweger et al., (2016) assert that there is a

correlation between homework compliance and a decline in depression. This justifies the

importance of homework in a therapeutic session.

During therapy sessions, the counselors assume the role of a director by using as much

skills as possible to enable them to take charge effectively. The clients can easily deduce that the

homework session will not proceed as intended in cases where they did not play an active role in

formulating the tasks (Sachsenweger, Fletcher & Clarke, 2016). Patient involvement at every

stage of the therapy is essential. Therefore, the counselor must pay keen attention to implement

and follow guidelines that will not deter the client from active participation during the session.

Offering adequate directives also assists the clients to identify their emotions and express their

thoughts with ease. To do so, I would ask Karen some questions such as Why do you think your

mother withdrew from her duties? so as to form a basis of letting her express her thoughts.

Additionally, the counselor must be didactic enough so as to come up with reasonable arguments

to ensure that the client understands the content matter from a reasonable perspective.
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Helplessness and hopelessness are two major symptoms of depression that make clients

to believe that their input in a therapeutic session would not have a significant effect on the

outcomes. This goes a long way to break their morale and by extension minimize their

participation in the sessions. The counselor is obligated to refute such beliefs and instead make

the client believe that their input will go a long way in helping them cope with depression. In

Karens case, I have to encourage her to be more devoted in her studies. The resolve to

participate in the homework is a yardstick to measure the resolve to face life and overcome her

challenges. With this understanding, I will impress upon Karen to accept that her mother has

tarnished her familys reputation because it is in the past.

As brought out in the case study, it is evident that Karens depressive symptoms originate

from the fear of the unknown and this limits her potential to share her problems with her peers

and close family members. As her mentor, I will advise her that keeping to oneself causes more

damage to both the body and soul and there is need for her to open up to friends. Clients

irrational beliefs can be appraised by using the ABC model that requires the counselor to figure

out the activating effects and their respective consequences (Australian Institute of Professional

Counsellors, n.d.). In this case, the activating effect is failure on the part of her family to

encourage her to air out her concerns. The counselor is also charged with responsibility of

ensuring that the client remains focused to benefit from the therapy sessions. By doing so, the

client will overcome the feeling of hopelessness and hopelessness and will be convinced that the

homework is geared towards making her overcome depression. The Australian Institute of

Professional Counselors (2017) observed that there are times when a client would agree with the

counselors line of thought but still find it difficult to have a change in their thinking. This is a

sign of hopelessness. Finally, the counselor has to make sure that the benefits of the therapy
COGNITIVE BEHAVIOR THERAPY 12

sessions outweigh the costs. Ajzens theory of planned behavior argues that a client has to do a

cost-benefit analysis before agreeing to undergo the therapy session (The Australian Institute of

Professional Counselors, 2017). In case the expected benefits outdo the costs, then there is a high

probability that the client will invest in the therapy. Nonetheless, if the costs outweigh the

benefits, then there is a low likelihood that the client will invest in the task.

The client also has an integral role to play in ensuring the success of the homework.

Clients must first accept the rationale of the treatment offered by the counselor. By doing so, the

client shows the willingness to take part in the therapeutic session actively and her conviction

that she believes that the therapy is to benefit her. In addition, the client must reveal all her

emotions so as to enable the counselor to make a reasonable decision on the best way to help her

overcome her situation.

A Plan for Treatment

The ultimate goal of the cognitive behavior therapist is to make sure that the client

overcomes depression, which encompasses long term and short term goals as well as intervention

measures that will help the client back to her normal best. Karens treatment plan will be based

on Aaron Becks tool - the Beck Depression Inventory (BDI-II) tool. Beck proposed that

depressed people are largely affected by logic errors which he called cognitive distortions. He

came up with the BDI-II as an aid to cognitive therapy whose major role is to screen the patient

for any depressive disorder as well as note the clients level of depression (Bellis, 1999). This

model is significant in helping patients engage in activities that would make them have a change

in their mode of thinking and eventually experience an overall change in their behaviors. The
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BDII model proposes that an individuals emotions, behaviors, thoughts, and even beliefs are

interconnected as illustrated in the figure below.

Figure 2: The interconnection between thoughts, emotions, beliefs, and behaviors of an

individual. Image location, Australian Institute of Professional Counselling. (n.d.).

Cognitive behavior therapy: A guide to counseling therapies (DVD). J & S Garrett Pty

Ltd.

The BDI-II helps one to identify symptoms relating to depression by noting whether

patient possess related characteristics such as a feeling of guilt, weight loss, loss of sleep, loss of

interest in ones hobbies and fatigue. The model comprises of twenty-one questions rated on a

scale of 0-3. The counselor uses the Socratic form of questioning - using open-ended questions -

(for instance asking the patient a question like How sure are you that it is pointless to try?) to

effectively assess the patients level of depression. Basing on this form of assessment, some of

the questions I would ask Karen include: What would you gain by sleeping the entire day? and

how do you know it will be a waste of time sharing your issues with your family? The BDI-II
COGNITIVE BEHAVIOR THERAPY 14

results are broadly classified into four groups; severe depression (29-63), minimal depression (0-

13), moderate depression (20-28), and mild depression (20-28).

The Short Term Goals

Short term refers to the immediate objectives that need to be achieved as a result of the

therapeutic session. By making use of the BDI-II assessment model, I will gauge Karens

probability of committing suicide. If the results turn out to be above the minimal level, then I

will suggest that a psychiatric assessment be performed. However, in this case, I will seek for

his fathers consent since Karen is still in junior high school and so she has not attained the legal

age to make such decisions.

Interventions

Some of the interventions that I would propose at this stage include requesting Karen and

her guardians to seek alternative from specialized professionals. Since Karen feels that she has

no other person whom she can express her feelings to apart from the counselor, I would suggest

that her class teacher maintains a close check on her so as to note signs of recovering. The class

teacher should also encourage Karen to be open to help her to identify he troubles and also

propose favorable measures of helping her overcome such troubles. Also, I would request that

her family attend some therapy sessions. Corey (2009) notes that family therapy session plays a

key role in encouraging family members to embrace each other, paying attention to the concern

of every member. Such sessions also enable the family members to accept that the actions of any

member affect all of them and, hence, they should always do their best and behave in an

acceptable manner for the sake of their families. Therefore, the therapy sessions would enable
COGNITIVE BEHAVIOR THERAPY 15

Karens family the need of listening to each other and, thus, help each other overcome their

troubles.

Long-Term Goals

The long-term goals are aimed at making sure that Karen successfully recovers from

depression and even avoid its recurrence in future. One of the major long-term objectives for this

therapy session was helping Karen to understand the connection between her belief system,

emotions, and behaviors. She has to understand that her fear was increased by the beliefs that she

was not supposed to share her troubles with her family members, which also made her, withdraw

socially. Therefore, it is important to clarify that her beliefs influence her emotions and

ultimately determine her behaviors. Another long term goal would be helping her realize the

cause and the nature of her problem. In this case, I would make her aware that she suffers from

depression that resulted from anxiety. In her case, depression may have set in as a result of her

belief that she is neglected by her close family and friends Additionally, the therapy session will

also be aimed at teaching her the essence of having a friend and a confidante to share her worries

with. It is important to note that there is likelihood that if she had a close friend, she would have

got someone to cheer her up after noting her continous sadness.

Intervention Measures

The major intervention measure that would be used is ABCDE strategies. For instance, I

would advise Karen to teach other students on the importance of doing away with mandatory

words and in their place use less forceful words (that do not imply finality) to make sure that she

adapts to the new preferred mode of thinking. Such a practice would also serve as a
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reinforcement to make sure she is able to effectively use the strategies learnt in the counseling

session. Additionally, bibliotherapic approaches have been noted to be significant the treatment

of anxiety disorders such as depression. Since therapy is an educational process, patients

suffering from depression may be encouraged to read rational emotive behavior therapy self-help

books such as Rational Emotive Behavior Therapy: It works for Me It Can Work for You by

Ellis.

Weaknesses of the CBT

Despite its importance in counseling sessions, CBT has several weaknesses one of them

being that it requires that the client be attentive to previous unconscious thoughts, which may not

be possible. For instance, it would be quite hard for Karen to explain what she was

unconsciously thinking of while in school as she spends her time alone. This creates a possibility

that her mind wonders on a range of unexplored issues. In addition, this method may not be as

effective as some people might want. This is the reason why the clients have to do a cost-benefit

analysis so as to decide whether it would be okay for them to invest their mind in it or not.

Strengths of the CBT

The CBT has some strength. Key among them being that it is supported by scientific

research and for this reason it works with the BDI-II. Scientific insight from such models enables

a counselor to decide on the best action to pursue after gauging the clients depression level.

Such knowledge played a significant role in making a decision that Karen should be referred to a

psychiatrist. Also, the CBT offers a clear sequence and plan for the therapy. This is well

illustrated by the steps Karen had to take during the counseling session, which ranges from being

questioned by the counselor to being accustomed to workings with self-help groups to help her

overcome depression fully.

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Conclusion

Depression is one of the psychological disorders that might have far-reaching

consequences such as committing suicide. As brought out in the case study, depression has

several causes. Some of them include cultural factors, gender roles, and even family beliefs and

practices. Cognitive behavioral therapy (CBT) is one of the best models that can enable a patient

to recover from psychological disorder. This method involves the close interaction of the

counselor and the client with a sole objective of identifying the major cause of depression and

the identification of the best ways that can work to overcome the disorder. CBT is widely used in

therapy sessions due to its nature of relying on scientific evidence such as the BDI-II and its

clear steps that have to be followed all through the session makes it easy to implement.
COGNITIVE BEHAVIOR THERAPY 18

References

Australian Institute of Professional Counselors. (n.d.). Cognitive behavior therapy. A guide to

counseling therapies (DVD). J & S Garrett Pty Ltd.

Bellis, C. (1999). The Beck Depression Inventory for Primary Care accurately screened for

major depressive disorders. Evidence Based Nursing, 2(4), 126-126.

Corey G. (2009). Theory and practice of counseling and psychotherapy. Thomson Brooks/cole.

National Alliance of Mental Illness. (2017). Depression. National Alliance of Mental Illness.

Retrieved from http://www.nami.org/Learn-More/Mental-Health-Conditions/Depression

Sachsenweger M. A., Fletcher R. B., Clarke D. (2016). Pessimism and homework in CBT for

depression. Research Gate.