Depression

Identifying Automatic thoughts

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Lots of people struggle with identifying their thinking. Some insist that they are “just anxious” and they have no worries creating this anxiety. While it may be the case that some health conditions can produce an anxiety like response, CBT suggests that the vast majority of the time there are thoughts or beliefs creating our emotions and there are some tools we can use to help identify them.

The “what am I feeling” technique

This is a fundamental technique in CBT. Our feelings are excellent clues into what we are thinking. Also, since we frequently misuse the word “feel” in English, sometimes our “feelings” are actually thoughts in disguise. For example, woman struggling with guilt about parenting insisted she couldn’t identify her thoughts when she felt guilty. When describing the situation in therapy she claimed “I just feel like a bad Mom.” This was immensely helpful because she had been confusing her feelings with her thoughts. She felt guilty and she thought “I’m a bad mom.”

Even when we are not confusing thoughts and feelings, our emotions give us hints about our thinking. As described above, when we are anxious we are usually worried about something, when we are depressed we are usually thinking negative thoughts about ourselves, the world, or our futures, and when we are angry we are usually thinking about what “should” happen or how someone “should” behave. Sadness tends to be about loss, guilt about judgments about our own behavior, and embarrassment tends to be created by assumptions about how others might judge us.

You can improve your skills of identifying your thoughts by checking-in with yourself next time you have a feeling. So next time you feel anxious ask yourself “what am I worrying about?”

The pen and paper technique

The first technique is very simple, but usually can be effective for most people. This technique involves carrying a small notebook, a piece of paper, or a cue card with you (and a pen) and writing down any automatic thoughts you have when you feel anxious, depressed, angry, etc. You can also use worksheets to help with this process. Here are some hints for writing down automatic thoughts:

  • Write your thoughts in short sentences like “I’m going to be late!” or “this person should learn to drive.” Do not write single word bullet points like “bad” or “guilty.”
  • Do not write your thoughts in the form of a question try and turn them into statements. For example, turn “Why am I such an idiot?” into “I’m such an idiot.”

The stick person technique

Although this one can seem silly, it can be one of the most effective skills for identifying thinking. Simple think of a time when you were feeling depressed, anxious, angry, etc. Then draw a stick person in that situation. Here’s an example of a stick-person getting anxious when they saw a snake when he was on a hike with his stick-girlfriend:

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Then simply guess or imagine what the stick-person might have been telling himself in this situation to create his anxiety.

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Usually, what we imagine the stick person might have been thinking is precisely what we were telling ourselves in this situation.

Meditation and free association

Other techniques to become more aware of our thinking include meditation and free association. These techniques encourage us to be mindful or our thoughts in the present moment.

Once we can identify our thoughts, we can then use cognitive-restructuring techniques to change the way we feel and/or behave.

Understanding the Origins of those Negative Predictions and Judgments

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tversky and kahneman

 

Amos Tversky (left) and Daniel Kahnement (right)

 

Daniel Kahneman won the Nobel Prize in 2002 for the work he, and fellow psychologist Amos Tversky, began in 1974 when they and published their article “Judgment under Uncertainty: Heuristics and Biases” in the esteemed academic journal Science (Vol 185. Pp. 1124-1131). Tversky and Kahneman sought to understand how humans made decisions in uncertain situations. This work suggests people use a series of mental processes to make decisions and the underlying machinery of these mental processes tends to make predictable errors. Their findings have profound implications for our understanding of mental health.

Anxiety 101 – a Review

Anxiety is the product of perceiving a threat to something we value. In the simplest terms, when we believe there is a bear (a threat) in the bush near us (something we value) our body gets ready to run/fight/or freeze (anxiety). This simple formula can take far more advanced forms because we can value other things besides our own physical health and threats can take many forms beside that of a bear. While threats and things we value can take many forms, our bodies only have a small number of responses. These responses are run, fight, or freeze and we interpret our bodies getting ready to do these things as anxiety. For example, public speaking is perceived to be a threat to our goal of being perceived as competent and confident, taking a test poses a threat to our hopes of completing a class with a particular grade, and running out of gas threatens our goal of getting where we want on time. Our bodies will get ready to deal with all of these threats in the same ways – by making us anxious.

An Available Heuristic

If we accept this formula as an explanation for why we get anxious, this leads to another reasonable question: How do we decide how much of a threat something is? Tversky and Kahneman provide us with an answer but first let’s consider some other questions:

  • When considering all of the words in the English language, which are three or more letters, are there more words with the letter K as the first letter, or more words with the letter K as the third letter?
  • What percentage of middle aged men will have a heart attack?
  • How honest are you?

To answer these questions our minds could use a number of different strategies. Our minds could list every known English word that is 3 or more letters, then compare how many begin with K and how many have K as the third letter. Even if we used this exhaustive and thorough strategy, our answers would be imperfect because we do not know every English word so we would be guessing based on the words we do know. As for the questions about heart attacks and honesty, we would never truly know the exact values because we are not omniscient and honesty is not something you can quantifiably measure. However, most people do not find it difficult to come up with answers to all of these questions. In fact, people tend to come up with answers extremely quickly.

When we are asked questions like these, our minds take the question we have been asked then quickly replace this very difficult question with a simpler question like “How easily can I remember or imagine something like this?”

If you are like most people, when asked the question about the letter K, you tried to think of words that begin with the letter K or had K as the third letter. If you could easily recall words beginning with K, but had greater difficulty thinking of words with K as the third letter, you concluded there must be more words beginning with K. Words with K tend to be easier to recall and most people assume there are more words beginning with K, even though there are more words with K as the third letter in English. Instead of being able to provide the true likelihood of heart attacks, our mind replaces this question with something like “How easily can you remember or imagine a middle aged man having a heart attack?” Then finally, you likely replaced the question about honesty with “How easily can I remember situations in which I was honest and dishonest?” It is not about how many memories we have being honest or dishonest, we form our judgments on the availability of those memories. Memories we can easily recall are said to be more available to our conscious minds than memories that are difficult to recall.

This mental “trick” is called the “availability heuristic.” As Tversky and Kahneman explain in their 1974 article, “There are situations in which people assess the frequency of a class or the probability of an event by the ease with which instances or occurrences can be brought to mind” (p. 1127). In other words, we believe something to be more likely if memories or fantasies of similar situations are “available” to our conscious mind. Most of the time the availability heuristic serves us pretty well. If something frequently happens in our life (the sun comes up every morning), one can assume it is likely for it to happen again without many costs being associated with this prediction. This allows us to avoid living in a constant state of uncertainty, predict what is likely to happen in the future, and plan accordingly. Unfortunately, the availability heuristic can be biased and sometimes this can have serious adverse consequences.

The availability heuristic is disproportionately influenced by recent and emotionally salient situations. Following a traumatic experience, people are far more likely to overestimate the probability of a similar traumatic event happening which artificially inflates our perceptions of how threatening a situation is, which in-turn unnecessarily increases anxiety and distress. Following a car accident, you will likely overestimate the likelihood of being in another car accident, which increases anxiety while driving. Following 9/11, many of us felt a new anxiety we did not previously experience while getting on air planes, not because flying was anymore dangerous (flying had probably never been safer than after 9/11) but because memories and fantasies of planes being high jacked were far more available.

Mental Process Underlying Mental Health Challenges

We determine which situations are threatening not by assessing the true threat level, but by assessing how easily we can remember or imagine similar situations ending-up poorly. Panic disorder can manifest in a number of ways, everyone is different, but people with panic disorder tend to worry that bodily sensations (heart arrhythmias, increased heart rates, accelerated breathing, dizziness, sweating, etc.) are evidence of a serious catastrophe (heart attack, stoke, going insane, etc.) which escalates anxiety resulting in panic attacks. Once we’ve had a single panic attack, the memory of this experience can be particularly available because panic attacks are so emotionally distressing. If we have had a panic attack in a store, we might later wonder about the possibility of having a panic attack in another store like Walmart. This question about the probability of having a panic attack in that particular Walmart at that particular time is replaced with “How easily can I imagine having a heart attack in Walmart?” If the answer is “very easily” then, we will assume the likelihood of having a panic attack in Walmart is high and we will likely avoid Walmart to avoid having another panic attack.

In obsessive-compulsive disorder (speaking of true OCD not the “OCD” people claim to have when they have strong preferences for cleanliness or organization), people can grossly overestimate the likelihood of someone breaking into their home and murdering their family because this specific fantasy can be incredibly distressing. When a fantasy is emotionally distressing, it is more available to consciousness, and this availability inflates perceptions of likelihood. Put simply, because the obsession is so upsetting, people will think it is likely, and they will act compulsively to reduce the probability of the feared event occurring.

In addition to anxiety disorders, the availability heuristic also plays a role in the development and maintenance of other mental health challenges. People with eating disorders often worry that people will judge them negatively if they were “fat.” They sometimes have vivid fantasies of being publically ridiculed or rejected for having what most people would consider to be an average or even below average weight. The maintenance of an eating disorder is riddled with availability heuristic errors. Often people will be able to easily imagine people judging them for being “fat” because they themselves frequently judge other people as fat and they take this as evidence suggesting other people have similar thoughts. The memory of their own judgments will be available because they are so frequent and this will inflate their perception about the likelihood of other people being judgmental like themselves. There are often historical traumas in childhood in which the person with the eating disorder was indeed bullied, mocked, and/or criticized, sometimes by close loved ones. While memories of this abuse are no longer recent, they may be incredibly available because of their emotional salience. They may also judge themselves as inadequate because they can easily recall examples of “beautiful” celebrities which inflates their perception of the regularity of these “beautiful” people.

When we are depressed, we will often have negative automatic thoughts about ourselves like “I’m a failure” or “I’m a loser.” Our minds will form these judgments by seeing which memories are most available, so if we can easily recall examples of “failures” or “losing”, we will be more likely to make judgments consistent with these memories. Since we tend to feel negative emotions more intensely than positive emotions, memories involving failure and loss may be easier to recall, and so these memories bias the availability heuristic and negatively distort our judgments.

Help is Available

The availability heuristic seems to be at the heart of many mental health challenges and this has some interesting implications for the treatment of mental illness. The availability heuristic is biased by recent and emotionally evoking memories and being aware of these biases allows us to think critically about the assumptions we make. In his 2011 book “Thinking, Fast and Slow” Daniel Kahneman explains “Resisting this large collection of potential availability biases is possible, but tiresome. You must make the effort to reconsider your impressions and intuitions by asking such questions as, ‘Is our belief that thefts by teenagers are a major problem due to a few recent instances in our neighborhood?’ or ‘could it be that I feel no need to get a flu shot because none of my acquaintances got the flu last year?’ Maintaining one’s vigilance against biases is a chore – but the change to avoid a costly mistake is sometimes worth the effort” (p. 131). This method of monitoring and thinking critically about our assumptions is identical to the cognitive restructuring interventions used in Cognitive-Behavioral Therapy.

In addition to cognitive restructuring, exposure based therapies may also be used to combat the biases of the availability heuristic. It’s no surprise that people tend to avoid anxiety provoking situations. As Dr. David Burns explains in his book When Panic Attacks:

Most people who are anxious avoid the things they fear, so they never experience enlightenment or relief. If you’re afraid of heights, you’ll avoid high places because they make you feel dizzy and anxious. If you’re shy, you’ll avoid people, because you feel so insecure and inadequate. The avoidance fuels your fears, and your anxiety mushrooms. If you want to be cured, you’ll have to face the thing you fear the most. There are no exceptions to this rule. (Pp. 252-253)

Imagine a person who has a panic attack on an elevator. Following this experience, when the person’s mind attempts to calculate how dangerous a particular elevator is, it will not be calculating the true risk of taking the elevator because this is truly unknowable for every elevator in the world at any given time. It’s not like their mind will know there is a 1.2496% chance something goes wrong if they get in that elevator right now and remain in it for 28 seconds. Instead, they will replace the question, “How dangerous is this elevator?” with “how easily can I recall having an uncomfortable emotional experience in situations similar to what I imagine it is like to be in that elevator?” The memory of their last panic attack in the elevator will be very available because it is so emotionally evoking, even if it is not recent, and so the person will conclude getting on the elevator will be very dangerous. However, if the person decides to go into the elevator, even though they feel anxious, there is very little chance anything will go wrong. They will likely feel anxious and perhaps even have another panic attack, but after a few minutes this anxiety will dissipate. If they stay until their anxiety is gone, they may even feel pride and excitement about their achievement. Let’s say they repeat this exposure exercise 5 or even 10 times. The next time they wonder about how dangerous it is to get on an elevator, the memories of taking the elevator with nothing bad happening will be far more available and they will conclude the elevator is likely safe.

I recommend combining both of these cognitive and behavioral (exposure) approaches. Be mindful of how and why your mind is making the predictions and judgments it is making, but also go and have positive experiences to replace the negative memories creating these predictions and judgments. As you change your assumptions, predictions, and judgments through cognitive restructuring and exposure, you’ll experience serious emotional changes.

To be thorough, lets consider an example in which a person is depressed. As mentioned above, people who are depressed frequently experience negative judgments and predictions. We can fight depression by identifying and thinking critically about these judgments and predictions. So when we tell ourselves things like “I really can’t do anything right” we notice these thoughts and write them down, or record them in some way. Writing down our thoughts is a great way of distancing ourselves from what we are thinking. Then we think critically about these thoughts by simply asking some questions like “What memories is my mind accessing when I think I can’t do anything right? Are there other examples of me doing things reasonably well that my availability heuristic is ignoring? I put my pants on today correctly, is that not an example of doing “anything” right? So if I have done somethings right, like putting on pants, what do I really mean when I think I can’t do anything right? Do I mean that I have some regrets and if so, how do I know I have more regrets than other people? Even I have done more regretful things, what can I do about it? What is the value to ruminating on these regrets?” So this is one example of a cognitive restructuring technique called Socratic Questioning.

To combine our cognitive restructuring with a behavioral technique to combat the biases of the availability heuristic, we might create a list of things we could do to have the experience of doing something right. To make this list we might ask, what are some things you would be proud to do? Things like hike a mountain, read a book, volunteer, get a job, take a class, or clean up a local park. Then the depressed person would go and do these things, even if they don’t feel motivated to do so (action comes first, motivation comes later). The person would take photos of how they did and this would serve as evidence to dispute future thoughts about not doing anything right. Combining both these cognitive and behavioral approaches will help the person to become less depressed over time by combating the availability heuristic’s biases for emotionally evoking and recent memories.

 Summary

To summarize, the availability heuristic is a mental process we use to make predictions and judgments. While it frequently helps us make complex decisions effectively, it is also biased to overemphasize recent and emotionally salient memories and fantasies. Unfortunately, these biases can create and maintain challenges like anxiety and depression. Cognitive restructuring and exposure techniques can help us challenge the underlying thinking which contributes to these problems.

 

Postscript

I’ve been studying the work of Tversky and Kahneman for several months now, beginning with the Michael Lewis book “The Undoing Project” which tells the amazing story of how they changed the world of psychology, economics, health care, finance, marketing, and so many more fields. Judgment under Uncertainty: Heuristics and Biases is a brilliant 7-page article that can be found for free – click here. Daniel Kahneman’s book Thinking, Fast and Slow is a fantastic insight into our minds and how they work.

Resisting Change and the Depressive Paradox

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“You can take a horse to water but you can’t make them drink.”

There are many reasons people resist making positive changes in their lives. As a therapist, the number of reasons I’ve heard for not making a change is truly astounding. When I talk about this with people, they explain it’s obvious – people don’t make changes because they “fear change.” I’ve always found this explanation to be unsatisfying. It sounds like another example of people wanting a simple explanation for something complicated. Why do people fear change? What specifically about change do people fear? I tried to answer these questions by reading Robert Leahy’s “Overcoming Resistance in Cognitive Therapy.” From this book, others like it, and my own experiences, I have learned resistance does not interfere with therapy, overcoming resistance is the therapy. Most people have an idea of how they could make a positive change in their lives, but they typically resist making these changes. One of the most interesting chapters in Leahy’s book describes the “Investment Model of Resistance” and how it applies to people with depression.

The Depressive Paradox

When people are depressed they are less likely to engage with activities which would likely reduce their depression. Instead of problem solving, exercising, socializing, working, sleeping 8 hours, and eating a healthy diet, people with depression are more likely to isolate, withdraw, conserve energy, and avoid. This is referred to as the “depressive paradox.” When people are depressed, one would expect them to be more motivated to pursue pleasure and meaningful engagement. Like how a starving person becomes intensely motivated to acquire food. From this perspective, avoiding potentially rewarding and enjoyable experiences seems to make no logical sense. As opposed to accepting a person with depression is simply illogical and self-destructive, Leahy’s Investment Model of Resistance suggests people with depression are primarily motivated to avoid losses, failures, and rejections, as opposed to being motivated by the possibility of acquiring the potential benefits of making a change. Like how a person who is intensely afraid of losing money will turn down a great investment opportunity because they cannot tolerate even a minimal amount of risk. Leahy suggests there is an underlying logic to the decision making of a depressed person, but this logic is based on distorted assumptions and beliefs.

The Cognitive Model of Depression

Aaron Beck is one of the founding fathers of Cognitive Behavioral Therapy. Beck’s Cognitive Model of Depression is an immensely valuable contribution to our understanding of depression. Beck suggests negative life experiences result in the formulation of dysfunctional assumptions about the self, the world, and the future. For example, people with abusive or neglectful parents may develop model 1the assumptions that they are truly inadequate losers, others are a source of rejection and criticism, and they will inevitably fail and end up in unsatisfying relationships or be abandoned. Our dysfunctional assumptions become triggered by critical incidents (losses, failures, criticism, rejection, etc.) and this results in negative automatic thoughts (“I’m a loser”, “why can’t I do anything right”, “I’m going to end up alone”, “I have no real friends”, etc.). These negative automatic thoughts lead to extreme emotional responses (sadness, hurt, guilt, anxiety, etc.) which then leads to exaggerated behavioral responses (withdrawing, isolating, defensiveness, people-pleasing, conserving energy, etc.). We describe this combination of unhelpful and distressing thoughts, feelings, and behaviors as depression.

Combining the Investment Model of Resistance and the Cognitive Model of Depression

I combined Leahy’s Investment Model of Resistance with Beck’s Cognitive Model of Depression in an attempt to better understand how depression can originate and be maintained. Once we formulate dysfunctional assumptions from negative life experiences we may try to avoid critical incidents which may confirm their dysfunctional assumptions. For example, if we believe that we are unattractive we avoid asking potential mates out on dates, because the rejection could trigger too much pain and hurt. Sometimes we can be moderately successful at avoiding critical incidents and we can be “fine” for a long time. Unfortunately, loss, failure, criticism, and rejection are unavoidable parts of the human experience regardless of how much we attempt to avoid or overcompensate. When we inevitably have one of these experiences, this activates our dysfunctional assumptions. We assume our skills are inadequate, we cannot cope with further losses/failures, and our resources are minimal (viewing energy and effort as finite and minimal). We fail to recall previous successes and assume/believe our lives have been an unending and unwavering pattern of misery which influences our predictions about the effectiveness of making positive changes. We also view the costs of even minor failures/losses as catastrophic and assume we will continue to fail into the future. As Leahy explains “To the depressive, losses are not simple inconveniences. Rather, they are interpreted as salient, personally relevant, morally significant, and predictive of further losses in other domains. Ironically, because losses are so overvalued, the depressive will avoid loss at all costs.”

model 2

The Investment Model of Resistance suggests when our dysfunctional assumptions are activated, we fear further failure and loss. This fear motivates us to avoid situations that could potentially give us some benefit (go for a run, call a friend, find a new job, enhance our education, prepare healthy meals, problem solve, etc.) because each of these situations also pose the possibility of failure, loss, and rejection. In some cases the costs of making a particular change are obvious (like financial costs), in other situations the costs are more discrete. An example of a discrete cost might be the loss of energy associated with making a particular change. Some ways we may avoid making changes include requiring more “motivation” prior to making a change, trying to not think about our problems (excessive distraction and sleeping for example), demanding a 100% guarantee we will succeed before trying, and insisting someone else solve our problems for us.

If we do muster the energy and motivation to try something, we often quit at the first sign of failure or loss. Many people that are depressed try problem solving, exercising, socializing, practicing gratitude, etc. Perhaps we tried once, for a week, a month, or maybe even 6 months but our depression undermines our attempts to make progress in a number of ways.

When we are depressed we have a high threshold for perceiving gains and a low threshold for perceiving costs. When we try something and don’t get a full remission of depressive symptoms, we conclude it didn’t work at all and if something even remotely undesirable happens, we believe it to be a catastrophe. Even minor losses/failures are turned into catastrophes by the person’s own excessive and unrealistic self-blame. This is sometimes “all or nothing thinking” or “catastrophizing” and is an example of cognitively distorted thinking. Take for example, the person who musters their courage to disagree with their partner for the first time in their relationship. Naturally, when we are setting boundaries we may be changing established relationship dynamics that may be working for the other people in our relationships. So when we are assertive and our partner responds with anger and frustration because we are trying to change the relationship dynamics that may be working just fine for them, we may have the negative automatic thought “I tried and it was a disaster.” In this example, we are failing to identify our gains – practicing our assertiveness skills and communicating our boundaries. It’s similar to the person who has never played basketball concluding they will never be able to play because they missed their first three point shot. Our high threshold for perceiving gains is also influenced by our causal explanations for our successes and failures. If we do something well, we blame transient and external factors like luck or the task being so easy anyone could do it. On the other hand, when we do something poorly we blame stable and internal factors like our own inadequacy. This reaffirms our distorted beliefs that we are inadequate, all we have done is fail, and all we will ever do will fail.

When we are trying to make positive changes in our lives costs often precede benefits. So if we quit after paying the cost of making a change but before attaining the benefits, we can conclude further effort would be futile. Furthermore, the benefits may be subtle and go undetected. For example, suppose you added daily exercise to your routine. Exercising costs us time, energy, and comfort before we get the eventual, but often subtle, benefits of exercise. In this situation, it may be easy to have the negative automatic thought “exercise doesn’t help at all, I exercise daily and still feel depressed.” However, our daily exercising may be providing us with the undetected benefits of protecting us from further depression, diabetes, hypertension, high cholesterol, chronic pain, etc. While it may be true that we are still depressed despite exercising, we cannot know how much worse we would be without exercising. Also, if exercising does not work (provide a complete remission of depressive symptoms) we also lose it as a possible solution to our problems. As the list of possible things we can do to get out of our depression gets shorter there is additional evidence for our dysfunctional assumptions that we are inadequate and will never get better.

Our outright avoidance of making potentially beneficial changes and our trying a solution but quitting before attaining benefits, not only undermines our problem solving but it actually creates new problems. For example, if we avoid exercising, we not only have to deal with our depression persisting but we may also develop serious health complications in the future. If we try to set boundaries with a behaviorally challenging teenaged child but we quit because it didn’t get the results we wanted quick enough, the child’s behavioral problems could continue to escalate and create new problems. Similar to the patterns above, the development of new problems then reinforces the assumptions about our inadequacy and our inevitable failure.

Sadder but Wiser

Leahy also identifies another aspect depression which may contribute to resistance of making positive changes. Leahy suggests people struggling with depression develop assumptions about being “sadder but wiser” which may reinforce their dysfunctional assumptions. From their experiences of perceiving constant failures and losses, they come to believe they have an accurate view of the world as negative, hostile, and filled with suffering. They may even derive some satisfaction and a sense of superiority from arguing with others about how their view of the world is accurate, which will reinforce these assumptions. Those struggling with depression may even use their own self-sabotaged attempts to make progress as evidence in support of their arguments. This is the “I’m going to fail, I’ll try but quit when I don’t get the results I want, oh look I failed, I was right all along” rationale. As explained by Leahy “By proving that he is correct about his negativity and that the therapist is Pollyannaish in his optimism, the depressive believes that he has achieved some “victory” – he has proven the therapist wrong. Even though this may add to his sense of hopelessness, he at least feels some momentary superiority to the ‘naïve therapist.’” Granted there is no shortage of horror, despair, and suffering in the world but to focus exclusively upon these aspects of the human experience provides a biased and cognitively distorted perspective. Although you may briefly feel satisfied and superior by arguing you are “sadder but wiser”, in my opinion the costs of remaining stuck greatly outweigh these potential benefits. I was unsure about how to add the development and maintenance of this “sadder but wiser” philosophy to my model but I thought it was an interesting idea and worth mentioning in this article.

Discussion

My combining The Cognitive Model of Depression and The Investment Model of Resistance is my attempt to explain how depression is developed and maintained. As opposed to being “afraid of change” or “irrational”, my model suggests people with depression are primarily motivated to resist making positive changes in their lives because of fears of further failure and loss associated with dysfunctional assumptions. I’ve kept Beck’s emphasis on the development of dysfunctional assumptions by negative life events and the activation of these assumptions by critical incidents. I’ve attempted to expand upon the “negative automatic thoughts” portion of Beck’s model by including cognitive processes from Leahy’s Investment Model of Resistance. In my combined model, negative automatic thoughts are expanded to include fears of further failure and loss, underestimating skills and coping abilities, viewing energy as limited and easily exhausted, distorted causal explanations for successes and failures, and all or nothing thinking about progress and failure. The model I created is cyclical, explaining why the depressed individual may become “stuck” indefinitely.

An astute critic of my model may notice I did not include a path out of this cycle. While I’ll likely expand my model in the future, my goal at this time was to better understand the resistance of someone struggling with depression. However, my research suggests there are likely benefits to helping the client identify and challenge assumptions of their own inadequacy and the cost/inevitability of failure through the use of a variety of cognitive and behavioral interventions. These interventions may include cognitive restructuring techniques, activity scheduling, behavioral experiments, exposure therapy, goal setting, and problem solving training (see previous articles for more information).

Leahy’s Investment Model of Resistance is significantly more complex than the model I have created. I should also note that Leahy does not provide a visual representation of his model in Overcoming Resistance in Cognitive Therapy and I have attempted to simplify and approximate how the various factors described by his model may interact. For more information on Leahy’s model, I recommend purchasing his book. The version of Beck’s Cognitive Model of Depression was from Cognitive Behaviour Therapy Case Studies by Thomas and Drake. While I have not conducted any studies to assess the validity of my model, it is consistent with the anecdotal accounts of many people I have met who have struggled with depression, some of which provided direct, but informal feedback, about this model.

I would also like to note that by attempting to identify how the decision making of a person struggling with depression may contribute to maintaining that depression, I am not attempting to blame anyone and make them feel worse. In fact my intentions are to help expand our understanding of depression, so we can better understand and help those struggling with depression. By focusing on what we can control, and the consequences of the decisions we make, we are empowered to make positive changes in our lives.