CBT for Medical Conditions
Depression is sometimes regarded as the common cold of psychiatric conditions. It is a debilitating condition, sapping individuals of their desire for life, for hope, for movement. This article will describe the negative effects depression has on chronic illness, how to recognize it, and how to encourage clients toward self-care.
Aaron Beck’s cognitive therapy was developed specifically as a treatment for depression. When his experiments failed to validate the psychoanalytic conceptualization of depression, Beck sought another way to understand the disorder. He recognized that depressed individuals had a negative view of the self, of others and the world, and of the future. Rather than anger turned inward, what characterized depression was this depressive triad, which could be triggered by external loss or which could arise from an internal disposition — one that may make an individual more sensitive to loss.
NEGATIVE VIEW OF SELF
NEGATIVE VIEW OF PERSONAL WORLD
NEGATIVE VIEW OF FUTURE
You see loss as Personal.
You criticize yourself unfairly. You label yourself as unlovable, inadequate, or worthless. You dwell on your perceived failures.
You see loss as Pervasive.
You generalize and magnify the scope of your loss. You see other people as superior or uncaring or unable to help. Your world may seem unfair, unkind, unfriendly, or cold. You dwell on how everything seems to be bad.
You see loss as Permanent.
You foretell the future, believing it will be bleak, devoid of pleasure or accomplishment. You believe that circumstances will not change, you will not feel any better. You see the future as hopeless, your fate as unchangeable. You dwell on how nothing will turn out right.
James, a divorced 53-year-old former handyman diagnosed with Non-Hodgkin’s Lymphoma, undergoes chemotherapy and struggles with depression: “I can’t function. I’m not glued together. Everything is falling apart… These doctors are going to kill me. How am I going to deal with this? I don’t trust anyone. They’re talking out of both sides of their mouths…. I have no more inner strength to continue this battle. I’m throwing the towel in. I’m giving in to overwhelming circumstances. It’s more than I can handle…. I feel like I’m stuck in hell with no escape. Death is better.”
The theme is loss: And a loss of health can bring about so many other losses. As a result of illness, James lost his energy, his independence, his job, his financial resources. And he lost a sense of security. He was frustrated by
- Physicians’ disagreements regarding treatment.
- Multiple tests he has undergone.
- Physicians not following through on promised phone calls.
A common depressive response to loss is avoidance. James would stay home, waiting for the phone to ring. He didn’t go out, and withdrew from life. Depression can be likened to a hibernation instinct. It tells people that trying to make an improvement in their lives is a waste of time and effort — as fruitless as a bear looking for food that’s buried under 12 feet of snow.
James saw himself negatively: “I can’t function. I’m not glued together.”
He saw his personal world negatively: “I don’t trust anyone. They’re talking out of both sides of their mouth.”
And he saw his future negatively: “I feel like I’m stuck in hell with no escape.”
Such ideas are painful and powerful. And they are untrue. When our clients believe them, though, they can give up, and go into a hibernation mode. Like James, their motivation drops. Their interest in life drops. And their energy level drops. Depression tells people to slow down, shut down, and retreat to their caves.
Obviously, this is not good for one’s health. It wasn’t good for James. And if it develops into a Major Depressive Episode, the effects can be quite devastating.
When illness triggers a loss of functioning, individuals may be prone to developing depression. Depression can worsen illness by making one less willing to provide self-care. These symptoms have a powerful effect. Peterson and Seligman (1987) looked at the press quotes of baseball Hall of Famers and found that those who saw losses as personal, pervasive, and permanent had more health problems and died at an earlier age than those who experienced loss differently. Their attitude alone didn’t mysteriously lead to death. They were just less apt to care for themselves; they were less vigilant in maintaining healthy habits and more apt to give up once they got sick. Without treatment, James could have easily gone this route. He didn’t. We worked steadily to counter these effects using the following strategies:
Depressed individuals coping with chronic illness may be so preoccupied with their infirmities that they lose sight of other aspects of their lives. The key is to focus on capabilities, rather than on limitations. We ask, “If the symptoms were the same, but your attitude changed, and you felt great about yourself, and more hopeful, what would change in your life? What would you do?” For James, it was clear. He would re-connect with friends. He would accept more help from his siblings. He would be less annoyed at their questions about his health. He would find more pleasurable and productive things to do. Goal setting helps to rekindle hope. It creates a vision for the future. We did just that, detailing what he’d like to do regarding work, volunteer activities, and self-education. We focused on what he’d like to see happen in his dating life, with his friends and family, and in his spiritual life. We listed what he could do in the areas of recreation, entertainment, fitness activities, and his own health care.
Weighing the costs and benefits of constructive action:
Individuals with depression may focus solely on the disadvantages of activation or making any efforts toward change. They often have negative thoughts that interfere with their motivation to engage in their goals. James thought, “I’m not healthy enough to go back to work— physically or mentally. It would be too taxing. I’d jeopardize my chances of getting disability.” He had thoughts about advocating for his health: “There are too many unknown factors to deal with. There’s too much pressure. There’s too much to deal with. I’ll just be in the same position. I may not have the emotional reserves to deal with treatment. I don’t want to kiss up to any more doctors.” In identifying these reservations, he already had done half of a cost-benefit analysis. Our job was to do the other half. He was able to identify the benefits of self-advocacy: “The doctor may give me some direction regarding my health. If I maintain my cool with this pressure, maybe I will have some answers about how things have been going.” And he noted something important happened when he become more active: “My energy level is starting to build.” We weighed the costs and benefits of constructive action, and the benefits came out on top. He posted them as a reminder.
Improving self-care and self-advocacy:
Depressed individuals may neglect their own health and isolate themselves. This is particularly risky for clients coping with chronic illness. James was able to fight this inclination. He attended programs at a nearby Wellness Center, and connected with other cancer survivors. He proudly showed me a poster he received on how to move from being a cancer victim to being a cancer victor. He connected with a program in integrative medicine and started to practice ways to improve his diet, his exercise, and his sleep habits. He even drew up his own Bill of Rights to state his wants and to encourage him to be more proactive regarding his health. These included asking doctors and staff to identify themselves as they came into the room and to state what they were going to do; having staff make an effort to help him feel more comfortable; and having staff answer his questions. This was quite a step for someone whom depression had stifled into silence.
In summary, depression makes any illness worse. Treating the depression enables clients to more effectively face the challenges presented by chronic illness. James was able to answer the negative beliefs about his future by focusing on his goals, hopes, and dreams for the future. He was able to modify his negative beliefs about himself by engaging in constructive action, seeing himself more realistically— as functional, more competent, and more in control. Finally, he was able to answer his negative beliefs about his personal world by connecting with other cancer victors, by advocating for himself, and by working with professionals who met (and even exceeded) his expectations. As a result of his efforts, both his cancer and his depression went into remission.
Beck, A.T. & Ward, C.H. Dreams of Depressed Patients Characteristic Themes in Manifest Content. Arch Gen Psychiatry. 1961;5(5):462-467.
Peterson, C., & Seligman, M. E. P. (1987). Explanatory style and illness. Journal of Personality, 55.237-265.