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Red de Revistas Científicas de América Latina, el Caribe, España y Portugal

Sistema de Información Científica

E. Thomas Dowd
Depression: Theory, assessment, and new directions in practice
International Journal of Clinical and Health Psychology, vol. 4, núm. 2, mayo, 2004, pp. 413-423,
Asociación Española de Psicología Conductual
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International Journal of Clinical and Health
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Asociación Española de Psicología Conductual

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The reader is cautioned that the relapse rate in depression is high. the Dysfunctional Attitude Scale and others. Depression consists of five different manifestations. Cognitive therapy. la terapia cognitiva. Nº 2. pp. the Beck Depression Inventory. It discusses the nature of depression. Thomas Dowd 1 (Kent State University. 4. motivational. A variety of cognitive depression instruments are discussed. A wide variety of therapeutic interventions for overcoming depression are presented. USA) (Recibido 22 octubre 2003 / Received October 22. vegetative & physical. 2003) ABSTRACT. Vol. and common cognitive assessment instruments of depression as well as some treatment techniques. evaluating. 2003) (Aceptado 30 Noviembre 2003 / Accepted November 30. cognitive.© International Journal of Clinical and Health Psychology ISSN 1697-2600 2004. although it is the emotional manifestation which we tend to think of as depression. 413-423 Depression: Theory. Three levels of . Ohio (USA) E-Mail: edowd@kent. Theoretical study. Cognitive distortions (or cognitive processes) are systematic errors in logic and reasoning that result in negative automatic thoughts. This theoretical study describes the phenomenon of depression and the use of cognitive therapy in its treatment. Kent State University. the cognitive therapy of depression. and new directions in practice E. and delusional. Depression. and core cognitive beliefs are discussed. KEYWORDS. 1 Correspondence: Department of Psychology. characteristic self-statements. Core cognitive beliefs or schemas are clusters of cognitive self-statements organized around one or more themes and have also been referred to as conditional beliefs or tacit knowledge structures. RESUMEN. assessment. and changing current automatic thoughts or self-statements. Se explora la naturaleza de la depresión. cognitive distortions. The include the Automatic Thoughts Questionnaire. Self-statement (or cognitive content) modification focuses on assessing. Este artículo describe el fenómeno de la depresión y el uso de la terapia cognitiva como tratamiento. emotional. Kent.

emocional. distorsiones cognitivas y creencias cognitivas. o Beck Depression Inventory. assessment and new directions así como instrumentos de evaluación cognitiva. and common cognitive assessment instruments of depression as well as some treatment techniques. Las distorsiones cognitivas (o procesos cognitivos) son errores sistemáticos de la lógica y el razonamiento que dan resultado a pensamientos negativos automáticos. But sometimes it is not self-limiting and requires psychological or psychiatric treatment and it is certainly more serious than a cold! In this article I shall discuss the nature of also included. La depresión se muestra en cinco manifestaciones diferentes (emocional. vegetativa y física. it is often called “The common cold of mental health. Se describen diversos instrumentos de evaluación cognitiva de la depresión: Automatic Thoughts Questionnaire. Nº 2 . especially when its milder form . Depresión: Theory. cognitiva. Terapia cognitiva. e crenças cognitivas nucleares. Esquemas ou crenças cognitivas nucleares são agrupamentos de auto-afirmações organizadas em volta de um ou mais temas e têm sido referidas como crenças condicionais ou estruturas de conhecimento tácito. São discutidos três níveis de cognição. Dysfunctional Attitude Scale. a terapia cognitiva da depressão. Tres niveles de cognición son discutidos: autoverbalizaciones. aunque es la manifestación emocional la que solemos considerar como depresión.414 DOWD. A modificação de auto-afirmações (ou conteúdo cognitivo) focalizase na avaliação e mudança de pensamentos e auto-afirmações automáticas. cognitiva.dysphoria . O leitor é avisado que o grau de recaída na depressão é elevado. the cognitive therapy of depression. 4. São discutidos vários instrumentos de depressão cognitiva. Este estudo teórico descreve o fenómeno da depressão e o uso da terapia cognitiva no seu tratamento Discute a natureza da depressão. È apresentada uma larga variedade de intervenções terapêuticas para lidar com a depressão. Terapia cognitiva. Beck Depression Inventory. Estudo teórico. In the United States. A depressão consiste de cinco manifestações diferentes. y delusoria). Depresión. motivacional. Depression is undoubtedly the most common mental health problem. Estudio teórico. e instrumentos de avaliação cognitiva da depressão assim como algumas técnicas de tratamento. Int J Clin Health Psychol. PALAVRAS CHAVE. e alucinatória. Se presenta una gran variedad de intervenciones terapéuticas para superar la depresión y se advierte al lector que la pauta de recaída de la depresión es alta. vegetativa & física. RESUMO. Vol. distorções cognitivas. o Dysfunctional Attitude Scale. motivacional. Distorções cognitivas (ou processos cognitivos) são erros sistemáticos na lógica e raciocínio que resultam em pensamentos automáticos negativos.” Most people occasionally are affected and in most cases it is self-limiting. auto-afirmações características. Las creencias cognitivas o esquemas son grupos de autoverbalizaciones cognitivas basadas en uno o más temas y que también se refieren a creencias condicionales o estructuras de conocimiento táctico. entre eles o Automatic Thoughts Questionnaire. etc. PALABRAS CLAVE. Depressão. La modificación de autoverbalizaciones (o contenido cognitivo) se enfoca en la evaluación y en el cambio de los actuales pensamientos automáticos. apesar de ser a manifestação emocional que tendemos a pensar como depressão.

Therefore the individual does not even look for other employment that in turn leads to further negative self-talk as well as further depressive feelings. Does the therapy directly change cognitive phenomena such as negative self-talk? Does the therapy provide a set of skills Int J Clin Health Psychol.g. 1979) saw it as characterized by a negative view of the self (e. “I’ve always been that way. “I am a loser”). other features such as difficulty making decisions. recurring thoughts of death. and delusional (A. Depression consists of five different manifestations. poor concentration or difficulty making decisions. emotional. Vol. Sometimes the cycles are long and sometimes the cycles are short. the world (e. and feelings of hopelessness. low self-esteem. this appears serious and obvious. affect or emotion. Depresión: Theory. motivational. 4.” During periods of depressed mood. feelings of worthlessness or guilt. vegetative & physical. Unipolar depression. let me distinguish among dysthymia. They might say.T.g. The original model of depression as developed by Aaron T. Nº 2 . But there appears to be a cycle of cognition. and the future (e. assessment and new directions 415 First. bipolar depression. difficulty in thinking or concentrating. 1996). Beck was careful not to say that these dysfunctional thinking patterns necessarily caused depression (though they might in some circumstances) but that they were associated with depression. people will hurt me if I give them a chance”). It is the emotional manifestation that we tend to think of as depression.T. at least two of the following additional symptoms are present. poor appetite or overeating. Bipolar depression was once called manic-depressive disorder and is characterized by mood swings from mania to depression. and behavior resulting in what has been called the downward spiral of depression. and psychological aspects likely causes depression.g. and motivational problems can also indicate depression. cognitive. “depression. things will never get better. 1993). only worse”). All that cognitive therapy or indeed any therapy can do is to help the patients manage their medication. although perhaps not as obviously. decreased energy. But it is not even certain what causes cognitive change in cognitive behavior therapy (Whisman. Dysthymia is a lowgrade chronic depression very much like a low-grade fever. To observers. Beck. For example. individuals may not even report them. “I am a hopeless loser” in response to a bad life event such as the loss of employment can result in feelings of sadness and apathy. Beck. is what is commonly meant by the word. Because of the long-standing and pervasive nature of these symptoms. the thought. 2000) as “a chronically depressed mood that occurs for most of the day more days than not for at least 2 years. low energy or fatigue. or thoughts or plans of suicide. sleep difficulties. Sometimes the mania is greater than the depression and sometimes the depression is greater than the mania. Bipolar disorder is a true medical condition and medication is the treatment of choice (Basco and Rush. There are also additional symptoms such as changes in appetite or weight. social factors. and unipolar depression. and Emery. A complex mixture of biological variables. While symptoms such as crying or emotional sadness are the most obvious symptoms. Shaw. generally major depressive disorder. loss of interest in pleasurable activities. Dysthymia is defined by the DSM IV-TR (American Psychiatric Association. trouble sleeping or too much sleeping. Beck (A.” It is characterized by one or more major depressive episodes (DSM-IV-TR). Rush. An episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. 1967).DOWD.” Others see them as always “down” or sad.

Only the comparison of cognitive therapy to wait list and placebo groups was consistently significant. depressed patients became less depressed as a result of therapy when behavioral strategies were used first and then followed by cognitive strategies rather than the reverse. there have been follow-up studies that indicate that cognitive behavior therapy may be associated with lower rates of relapse than other treatments (e. Dowd. Gelfand. Dobson & Dozois. In summary. He admitted. 1992. While even the most promising of these studies have not shown that cognitive behavior therapy is consistently and significantly better than alternative forms of treatment. 1983). Beck et al. assessment and new directions that helps patients handle these negative self-statements when they do occur? Does the cognitive rationale provide hope and optimism? We don’t yet know..g. as A. 4. Keith Dobson and his colleagues have performed two meta-analyses (Dobson. including wait list and placebo. 1998) that have examined comparisons of cognitive therapy for depression to alternative therapies and control groups.. Tang. Hollon. 1989. 1999. 1989). The results of the second metaanalysis were considerably less optimistic. and other psychotherapies. When cognitive strategies were followed by behavioral strategies.T. Trunzo. Depresión: Theory. 1998). however. that some of the studies he used were methodologically weak and the number of studies for some comparisons was small. A number of outcome studies have consistently shown that cognitive behavior therapy is at least as effective as pharmacotherapy (medication maintenance) for the treatment of acute symptoms.416 DOWD. cognitive therapy may provide patients with coping skills or revised thinking patterns they can use in handling future problems. it appears that changing these dysfunctional thinking patterns can reduce depression. Whether the thoughts or the behavior comes first. While it has not been Int J Clin Health Psychol. 2003. there was a period of relapse and the patients never did improve as much as those in the first group. Nº 2 . as I showed in a study years ago (Kelly. Hollon et al. it is better to begin with behavioral change strategies. he conducted a second meta-analysis that investigated follow-up effects and used the Hamilton Rating Scale in addition to the Beck Depression Inventory. (1979) pointed out years ago. Vol.g. Evans et al. medications. However. Dobson (1989) found that cognitive therapy was superior in outcome to all comparisons. On the other hand. some later studies have showed that cognitive behavior therapy is at least as effective as pharmacotherapy even for severely depressed patients (e. 1992). Nezu. and Duffey. Perhaps. Aaron Beck thought that cognitive therapy was not used appropriately in one of the sites in the original NIMH study so perhaps those results should not be seen as the best comparison of cognitive therapy with other treatments for depression. cognitive behavior therapy has been shown to be useful in helping people to overcome or at least reduce their level of depression. Thus. In an attempt to remedy these problems. Nezu. and pharmacotherapy (Imipramine) were equally effective with less severe cases of depression but that Imipramine was more effective for people with more severe depression (Elkin et al. interpersonal therapy. The famous study in the United States sponsored by the National Institute of Mental Health (NIMH) showed that cognitive therapy.. DeRubeis. behavior therapy. and McClure. Cognitive therapy has been shown to be of great benefit in helping clients to overcome unipolar depression as well as probably dysthymia. and Simons.

The next level of cognition is known as cognitive processes. The unspoken assumption was that this evaluation would demonstrate to patients how unrealistic their negative automatic thoughts really were so they could be replaced with presumably more realistic and positive automatic thoughts. They are sometimes referred to as surface cognitions or cognitive content. These are the cognitive distortions identified by J. The automatic thoughts are examples of what we think.” These are thoughts or verbal images that are involuntary and are part of the human stream of consciousness. Colvin. There is even evidence that it may be especially valuable in preventing relapse. dichotomous thinking. Block. with more of the former than the latter. patients can usually begin to recognize them with help from the therapist. In healthy people. Vol. An internal dialogue of 50% . and changing automatic thoughts or self-statements. Originally.50% was called the “internal dialogue of conflict. however. and discounting the positive. Too much honesty about yourself may be bad for your mental health! Unrealistically positive views may not always be best. A ratio well below 50-50 was associated with depression whereas a ratio well about .S. The early cognitive therapy for depression focused on identifying these negative automatic thoughts and evaluating the evidence for and against them. Schwartz and Garamoni (1989) found that an optimal level of mental health was characterized by a ratio of positive to negative selfstatements of . Therefore. There are other cognitive models that look at cognitive processing errors that may be associated Int J Clin Health Psychol. 2000) found that students who were unrealistically positive about their academic abilities received higher grades the following term than students who were realistic or unrealistically negative about their abilities. “I’ll never be able to give a good speech. However. Alloy and Abramson (1979) found something really quite annoying. evaluating. Beck and are examples of how we think. these thoughts consist of a mixture of positive and negative. Nº 2 . Depresión: Theory. In depression they are mostly negative. magnification/minimization. In partial support. assessment and new directions 417 shown to be consistently and significantly better than alternative treatments. Because they are involuntary and unrecognized they are not evaluated to see if they are true or even plausible. Although they are unrecognized. They can be thought of as systematic errors in logic and reasoning that result in negative automatic thoughts. They discovered “depressive realism” which means that depressed people often perceive things more realistically and accurately than do nondepressed people! Taylor and Brown (1988) reviewed evidence that demonstrated unrealistically positive self-perceptions are related to better mental health.” Perhaps a little self-delusion is helpful but much self-delusion is not. it seems to be at least as effective even for cases of serious depression. such as.62 was associated with an overly “Pollyannaish” attitude. such as personalization. it has been found that most people think they are above average.62.DOWD. another study (Wright. which is a statistical impossibility. In general. “I’ll never understand this class” or. These are the types of thoughts that people have about many events in their lives. the cognitive behavior therapy of depression focused on assessing. 4. and Funder (1995) found that overly positive self-evaluations (compared to trained examiners or friends) resulted in more negative interpersonal ratings of their personality characteristics by these raters. a certain amount of self-deception may be helpful to people’s mental health and even their behavior and may act as an antidote to depression.

The BDI consists of 21 items. in which we compare ourselves negatively to others. and global attributions for bad events and external. Spielberger. Ritterband.g. 1961).” Examples of core beliefs are. and Failure. is also associated with depression. current problems. such as Emotional Deprivation.” or “People can’t be trusted. 4. dysfunctional EMSs that may be responsible for their problems. Mook. and problem solving ability were each related to depression. and Brunner (2003) attempted to identify two separate factors of cognitive and affective components of depression. Several of these EMSs may be associated with depression. measured collectively by 40 items drawn from the BDI and three other depression measures. Metalsky. and Alloy. “Lieben und Arbeiten. sometimes known as tacit or implicit knowledge (Dowd and Courchaine. it should not be used to assess the presence of depression. so they are extremely resistant to assessment and change. Ward. Pengilly and Dowd (2000) found the level and amount of social support to be important as a buffer to depression. for this purpose. Depresión: Theory. they found two factors that identified the presence (Dysthymia) or absence (Euthymia) of state and trait depression. and reflect attitudes and symptoms frequently shown in depressed patients. Schemas can be seen as clusters of cognitive self-statements organized around one or more themes and have also been referred to as conditional beliefs or core cognitive schemas (J. Beck. and one’s place in the world. which are rated for intensity on a scale of 0 to 3. He defined a schema as a broad and pervasive theme or pattern regarding one’s self and relationship to others. “If I never offend anyone. 1995). It is commonly used. Because the BDI scores can be elevated for reasons other than depression (e.” (To love and to work). I’m unlovable. They are typically experienced by people as.” These can be seen as tacit rules about oneself. Negative social comparisons. The helplessness/hopelessness theory of depression (Abramson. Self-schemas. Young hypothesized that patients generally have two. Mendelson. “I’m inadequate. and that is dysfunctional. Self-esteem seems to be a mediating variable because it acts as a buffer to depression in people who otherwise might be expected on the basis of their cognitive content and cognitive processes to become depressed. Abandonment/Instability. “That’s just the way things are!” Perhaps the most comprehensive organization of core cognitive schemas are the Early Maladaptive Schemas (EMSs) developed by Young (2003). low self-esteem). The third level of cognition is that of schemas or enduring structural components of cognition. Perhaps the best known is the Beck Depression Inventory (BDI. These rules are laid down early in life. that developed during childhood or adolescence. are especially important. 1996). the world. It is a self-report measure and is best used as a measure of the severity of depression. An example of a conditional belief might be. and Erbaugh. however. Int J Clin Health Psychol. stable. Instead of finding cognitive and affective factors. There are currently 18 EMSs that are organized into five clusters. Vol. sometimes three. It can be especially useful for measuring session-by-session changes in depression. There are a variety of ways of measuring depression. Notice how the first two examples are restatements of Freud’s answer regarding what people ought to be able to do well. 1989) suggested that depression is caused by internal. Miner and Dowd (1996) found that negative life events. however. Beck. or schemas about one’s self.S. often before children can use language well. Nº 2 .418 DOWD. Defectiveness/Shame.” I’m a failure. Reheiser. and specific attributions for good events. unstable. assessment and new directions with depression. then people will like me.

The correlation between the State-Trait Anxiety Inventory (Spielberger. de los Santos-Roig. is rather high. A. Responses are scored according to criteria for irrational depressive thinking. 1974) is a measure of the hopelessness component of depression and is a good measure of suicide potential. Weissman and Beck. and tacit rules about self-evaluation and assesses the extent to which patients agree with certain depressogenic beliefs and attitudes. 1978) is used to measure core assumptions. Again. cognitive therapy appears to reduce relapse more than some other therapies. in his Handbook of Cognitive Therapy Int J Clin Health Psychol. In general. They also found two factors. Rian Mullin. The Cognitive Response Test (CRT. Because clinicians score it. cognitive. Its 17 items are scored by one or two trained observers and can assess affective (emotional).. assessment and new directions 419 Spielberger and his colleagues have also investigated psychometric data for the Spanish experimental version of the State-Trait Depression Questionnaire. and Buela-Casal (2002b).. two factors of Dysthymia and Euthymia were identified. The Automatic Thoughts Questionnaire (ATQ. behavioral.T. The Hamilton Rating Scale for Depression (HRSD. I now present some therapeutic interventions for overcoming depression. Spielberger. The Beck Hopelessness Scale (BHS. Carretero-Dios.71. Beck. The Daily Record of Dysfunctional Thoughts (A. T. 1970) and all scales in the study was high. the more likely the patient is to relapse. Patients are asked to complete sentences such as.” with the first thought that comes into their mind. 1976) assesses dysfunctional cognitive processes by asking patients to select one of four possible responses to six problematic situations. regardless of the type of therapy used. 1980) assesses the frequency with which 30 depression-related thoughts have spontaneously entered the patient’s head during the last week. and vegetative (lack of motivation) components of depression. These are most commonly concerning social approval and perfectionist standards of performance.. Depresión: Theory. indicating the scale is a sensitive measure of transitory depression. found an internal consistency reliability of . Women scored as more depressed than men. Weissman. beliefs. Hamilton. in their Cognitive Therapy of Depression. let me caution the reader that the relapse rate for depression. and Lushene. 4. investigating the State sub-scale. Beck et al. found they were able to induce State depression by appropriate experimental manipulations. Hollon and Kendall. the more severe the depression and the more frequent the depressive episodes. Vol. Lester. it is less vulnerable to self-presentational bias. investigating the Trait sub-scale.95 and a test-retest reliability (3+ months) of . 1967) is a clinicianscored measure that can be used to assess the presence of depression. First. 1979) is a less-structured instrument in which patients record their spontaneous automatic thoughts in situations that arouse unpleasant emotions. 1983) provides a more open-ended measure of dysfunctional depressive thinking. Gorsuch. and Buela-Casal (2002a). Carretero-Dios. Watkins and Rush. indicating a significant correlation between anxiety and depression. as I mentioned earlier. and Trexler. (1979). Spielberger. Hammen and Krantz. included a list of techniques. “When I consider being married. For example. But.DOWD. Beck et al. The Dysfunctional Attitude Scale (DAS. There are several measures of depressive cognitions. The Cognitive Bias Questionnaire (CBQ. Dysthymia and Euthymia. Nº 2 . This list has been expanded over the years and now has become quite comprehensive. de los Santos-Roig.

lists 75 different techniques and this list is not comprehensive.Behavioral experiments .Relaxation exercises . TABLE 1.Exposure hierarchies . Hilsman and Garber (1995) found this was true. A depressive episode may be triggered by a stressful life event. Vol. Some of the more common cognitive therapy techniques that might be useful in reducing depression are shown in Table 1. There is also a significant correlation between the number of negative life events experienced over time and the level of depression.Reduction of stimulants .Activity scheduling/monitoring . Students who reported a negative. Depresión: Theory.Exercise .Assertiveness training .Graded task assignments . Nº 2 . stress) to contribute to the onset and maintenance of depression.Thought-stopping .Cognitive rehearsal .Role playing . people who have a negative cognitive style are more likely to become depressed when they experience stressful life events than are people who do not have such a style. Of course.Active listening to therapy tape Cognitive .Positive self-statement logs .Modifying images . depressive.Acting “as if” . 4.Time management .Examining advantages & Disadvantages Recent research in the cognitive therapy of depression has shown the importance of the cognitive diathesis-stress model of depression.Flash cards/posters .Labeling distortions .Self-instruction ..Social skills training . Typical Techniques in Cognitive Therapy. Overholser (1996) found that depressed patients reported experiencing significantly more stressful life events during the last six months than did nondepressed people. Are people depressed because of stress in their lives or do they report more stress because they are depressed? Does the direction matter? In any event. explanatory style for their lack of academic control and competence reported more distress after receiving poor grades than did students without such cognitions. Thus.Evaluating automatic thoughts .Imaging feared consequences (“What’s the worst.Problem-solving . assessment and new directions Techniques (1986). there are techniques that we can use to reduce stress and therefore depression. Behavioral .?”) .Restructuring beliefs . These are shown in Table 2..Historical exploration & review of the evidence .g. This model proposes that negative cognitions are a vulnerability factor that interacts with negative life events (e.420 DOWD. Int J Clin Health Psychol. the direction of causality is not always clear.Distraction techniques .Identifying underlying beliefs .

10. Availability of family and social resources can help reduce depression. In summary.and when . future-orientation instead of a past. Reduce confrontation with others. 1.T. Includes reducing negative emotions by alcohol or drug use. the cognitive therapy of depression is considerably more complex than we once thought. depressed people have great difficulty remembering times when they were happy. through mood state congruence. and social causes . 11.) watching television. etc. Reduce habitual reactions. solution implementation and verification). 13. which increases depression. blame themselves for past events. Also. Repeated failure promotes a sense of well as situational causes. 4. 14. Relapse is more of a problem than we once thought and the more depressive episodes people have had..” 2. hopeless orientation. But recurrent. problem definition and formulation. Help clients express negative emotions but do not dwell on them. Disrupt the habit basis of maladaptive coping. Use of positive thoughts can help reduce depressive effects of negative life events. global causes. 1998). 7. 3. overeating. Utilize client’s social resources. or thoughts related to the problem. Focus on solutions instead of problems.g. historical. stable. Therapist can be a “problem-solver” and apply the 5 processes (problem orientation. Use problem-solving techniques. It will increase depression in the short run. Vol. 5. Maintain a sense of control. Use Reframing.. Reduce perfectionistic tendencies. Reduce tendencies for social withdrawal. the more likely they are to relapse. Int J Clin Health Psychol. avoiding people. A. Perceived uncontrollability reduces patients’ motivation. Depresión: Theory. Lack of effective problem-solving can make people vulnerable to depression. generation of alternatives. Beck’s et al. 9. decision making. (1979) original proposal that it could be cured in 16 session now seems overly optimistic . 4. 12. assessment and new directions TABLE 2. Nº 2 .and how?” 8. engage in wishful thinking.g. “What will you do . Coping with Precipitating Events. Encourage “Task focused” Coping.though that still might be true in cases of first-episode. Encourage or push a small change to start a “ripple effect. This encourages a hopeful. Focus on positive and happy experiences. Depression has been linked with withdrawing from people and events and (e. “Why did this happen to me? Self-blame immobilizes and depresses. It is the examination of the positive aspects of a situation commonly interpreted as negative. which reduces control. These avoidance strategies are strongly related to depression. 6. Reduce coping by avoidance. Depressed people are likely to attribute negative life experiences to internal. Reduce tendencies for rumination and blame. Confront the problem directly.. Depressed patients tend to avoid the problem and engage in “emotion-focused” coping. Art Nezu and his colleagues have developed a problem solving therapy for depression Nezu et al. characterological depression may have biological. Patients may ruminate. Encourage small actions which can increase feelings of control. Depressed people may have unrealistically high standards and use dichotomous thinking. e. acute depression.421 DOWD. It is truly a demanding problem. May ask unproductive questions like. People may respond to stress by being hostile or aggressive to others. Help them to reattribute through examination of the evidence.

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