The Psychological Treatment of Depression

304 Pages·2013·1.878 MB·English

by  Williams, J. Mark G

The psychological treatment of depression
Over the past decade, Cognitive Behaviour Therapy (CBT) has become
established as an effective treatment for clinical depression. Research studies
throughout the world have found that CBT is as effective as the best
antidepressant drugs in the short term, and that it has longer-lasting effects
than medication.
The Psychological Treatment of Depression describes the wide range of
cognitive behavioural techniques in great detail, enabling therapists to put
them to practical use. The author draws together assessment and treatment
techniques of proven efficacy, describing them in usable detail, and setting
them in the context of current psychological theories of depression. Some of
these techniques are suitable for out-patient or primary care work, others for
in-patients who may have been severely depressed for a long time. Some
techniques lend themselves to long-term strategies, others to brief therapy
interventions. In all cases, the techniques are explored in sufficient detail that
practitioners new to CBT can feel confident about using them and that those
already using them can update their skills. The final chapters discuss recent
advances in research on vulnerability to depression and recent theories about
what processes underlie successful therapy.
Basic and clear, with explicit case studies, sample dialogues, checklists,
and other helpful aids, the book is a splendid working manual, a field guide
for all mental health practitioners in any discipline who want to apply or
incorporate the successful methods of CBT into their work with depressed
patients.
The psychological treatment
of depression

A guide to the theory and practice of
cognitive behaviour therapy
Second edition
J.Mark G.Williams
First published by Croom Helm in 1984

This second edition first published in 1992
by Routledge
11 New Fetter Lane, London EC4P 4EE

Simultaneously published in the USA and Canada
by Routledge, Chapman and Hall, Inc.
29 West 35th Street, New York, NY 10001

Routledge is an imprint of the Taylor & Francis Group

This edition published in the Taylor & Francis e-Library, 2003.

© 1984, 1992 J.Mark G.Williams
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.

British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library

Library of Congress Cataloguing in Publication Data
A catalogue record for this book is available from the Library of Congress

ISBN 0-203-41490-X Master e-book ISBN

ISBN 0-203-72314-7 (Adobe eReader Format)
ISBN 0-415-06743-X (hbk)
ISBN 0-415-06744-8 (pbk)
Contents
Preface to the first edition ix
Acknowledgements for the first edition xi
Preface to the second edition xiii
1 Introduction 1
2 Psychological models of depression I: The behavioural
background 11
3 Psychological models of depression II: The cognitive
foreground 26
4 Psychological treatment of depression: Outcome studies 44
5 The assessment of depression: Some representative
procedures 77
Appendix A—Hamilton Rating Scale for Depression 83
Appendix B—The Beck Depression Inventory 91
Appendix C—The Cognitive Style Test 93
Appendix D—Dysfunctional Attitude Scale 100
Appendix E—Hopelessness Scale 104
Appendix F—Self-Control Schedule 106
6 Treatment techniques I: Overview, basic behavioural
techniques and symptom management 110
7 Treatment techniques II: Cognitive strategies 143
8 Treatment techniques III: Behavioural and cognitive
therapy for chronic and unremitting depression 178
9 Training exercises 201
10 The cognitive theory of depression revisited 218
v
vi Contents
11 Cognitive-behavioural therapy and the process of change 249
References 268
Name index 283
Subject index 286
Tables and figures

TABLES
1.1 List of symptoms used to diagnose major depressive disorder 5
1.2 List of symptoms contributing to diagnosis of ‘minor depressive
disorder’ 5
1.3 Newcastle diagnostic scale for endogenous depression 8
1.4 List of symptoms used by Spitzer et al. (1978) to distinguish
endogenous-type depression 9
2.1 Summary of four behavioural formulations 16
3.1 Possible attributions for failing an exam 27
3.2 Factors in childhood history leading to depressive schemas 33
3.3 Schemas which occur in personality disordered patients 34
4.1 Treatment components in cognitive-behavioural therapies 45
4.2 List of variables assessed in McLean and Hakstian (1979) 53
4.3 Proportion of patients in remission at end of treatment 65
4.4 Percentage change scores on Beck Depression Inventory 68
4.5 Percentage of patients relapsing following initial recovery after
antidepressant acute or maintenance treatment 73
4.6 Percentage of patients relapsing following initial recovery after
acute treatment by antidepressants, cognitive therapy or the
combination 74
6.1 Diary (to be completed each night before going to bed) 119
6.2 Sample list of activities for activity scheduling 125
6.3 Activities found by Lewinsohn to be associated with mood for
10 per cent of his sample 125
6.4 Activity schedule 132
6.5 A fear survey schedule 136
7.1 Thought diary 146
7.2 Activity and thoughts diary 147
7.3 List of negative thoughts for frequency ratings 149
8.1 Specification of problems and goals for Sarah Jane 188
8.2 Subcategories of verbal interactions 197
vii
viii Tables and figures
8.3 Reciprocal contracts negotiated by Sarah Jane and her husband
Jack during marital therapy 199
10.1 Correlations of attributional style subscales for negative
outcomes with degree of mood disturbance (MAACL) following
mid-term exam results 228
10.2 Comparison of correlations between attributions and
subsequent mood disturbances with or without exam
disappointment 228
10.3 Beliefs that persisted after recovery from depression treated
with amtriptyline 235
FIGURES
5.1 Possible format for daily or weekly recording of Beck
Depression Inventory 92
5.2 Possible format for daily or weekly recording of Hopelessness
scores 106
6.1 Diagrammatic representation of relative proportion of cognitive
and behavioural techniques used as a function of stage in
therapy and/or severity of depression 112
Preface to the first edition

It was not until the late 1960s and early 1970s that behavioural and
cognitive approaches began to be applied in the treatment of clinical
depression. Like the earlier applications of behavioural techniques for
anxiety-based disorders, researchers have since used a variety of strategies
to investigate efficacy and elucidate the factors affecting successful
treatment outcome. Single case studies in the early writings have given way
to treatment analogue studies and subsequently to larger scale outcome
studies with clinical groups. There now exist several careful reviews of
these studies. Although each of these points to areas in the outcome
literature where there are problems in interpretation, the reviewers
converge on the same conclusion: ‘Generally, behavioural and cognitive
strategies can have a significant effect on depression’ (Rehm and Kornblith,
1979); ‘From these studies, there appears adequate evidence that
depressives can respond to psychological intervention’ (Whitehead, 1979);
‘Several of the specific behavioural and cognitive-behavioural interventions
appear to have survived initial tests of efficacy’ (Hollon, 1981).
These reviewers also agree that combinations of cognitive and behavioural
techniques seem to be more effective in ameliorating depression than either
alone and their conclusions suggest that clinicians may be optimistic in using
such techniques or combinations of techniques in their therapeutic practice;
but how to proceed? The problem is that, although some techniques have
rationales and procedures which have been clearly documented by their
proponents (e.g. the excellent Cognitive Therapy Manual by Beck et al., 1979),
this is by no means true for all the techniques which the reviewers of outcome
studies cite as being effective therapeutic strategies. Some techniques which
hold out clear promise as effective practices are to be found only in partial
descriptions, scattered throughout the behavioural literature. When such
studies are reviewed, the reviewer rarely has sufficient space to give more
than one or two sentences to describe the technique under consideration. We
end up knowing something of what might be most therapeutic for our clients,
but little or nothing about how to go about it. It is to help fill this gap that
this book has been written.
ix
x Preface to the first edition
The techniques I have chosen to describe represent a range of those currently
practised by cognitive-behavioural therapists. Some are suitable for inpatient
management, others more suitable for outpatient or primary care work. Some
are suitable long-term strategies, others more suitable for brief therapy
interventions. The therapy chapters form the central portion of the book.
Their aim is to describe the techniques in sufficient detail to be useful for
clinicians who want to apply such methods in their work with depressed
patients, and as such, they are not written as a justification of these methods
over and above alternative treatment approaches. Had space permitted it
might have been possible to give details of more broad-based
psychotherapeutic approaches, or of the new and challenging field of clinical
ecology. (Readers interested in introductions to these fields might refer to
Malan (1979) and Rippere and Adams (1982) respectively.) Unlike the
arguments surrounding the growth of behaviour therapy for anxiety-based
disorders, there is now a more constructive debate between proponents of
different therapeutic schools. Each is more prepared to believe that patients
differ in the extent to which they benefit from the techniques of the different
therapeutic schools. The responsibility of practitioners of each orientation is
to make plain what methods are used in their particular therapy so that
individual clinicians may choose rationally which approach is appropriate
for which patient. Such a description of cognitive-behavioural techniques is
what is attempted as the central aspect of this book.
Preceding the core therapy chapters is a chapter on assessment which gives
a representative range of techniques (e.g. Beck, Hamilton) in full. The therapy
chapters are followed by a section on training exercises which aims to give
clinicians ideas to use in development of their own skills.
The book begins and ends on a theoretical note: the first two chapters set
the context for psychological approaches to depression; the last two raise
some basic theoretical and research issues. I hope these more theoretical
sections will be of interest to students of psychology, clinical psychology and
psychiatry in their ‘abnormal psychology’ or ‘experimental
psychopathology’ courses. However, the book will have fulfilled its purpose
if it provides for the clinician an introduction to and encouragement to try
out techniques, the utility of which can only ultimately be judged in the
clinical situation itself.