Yet, as adults, we also learn. In romantic relationships, couples report having to learn how to interact successfully with their partners. College students routinely report being better at reading, studying, paper writing, and test taking as seniors than as freshmen. They have learned how to be students while they were students. Now close to graduating, some view they have finally mastered the role. Ideally, of course, we would have the necessary information in hand before we needed it. We would already know, without being told, what makes a loved one angry or frustrated. All students would be spared the frustration of working hard on a paper and having it not be well received. Especially, researchers would never make mistakes.

Indeed, some individuals go through life believing that they should know how to do something ahead of time. In this view, mistakes are aberrations. After making a mistake, individuals can torture themselves with repeated accusations and self-blame. They see their foibles as an indication of their own lack of capability as a person. Some plunge into despair and conclude they will never sustain a romantic relationship, succeed in college, or complete a valuable research project.

Nevertheless, the reality is that learning is a process and that mistakes, including costly ones, are integral to that process. Although reading, teaching, and guidance are helpful, there are key aspects -- for example, of romantic relationships, college course work, and research methodology-- that are mastered through experience. Usually, although not always, humans get better at something through practice. This learning process can be exhilarating, difficult, boring, uplifting, lonely, exciting, frustrating, and scary.

This dissertation is about learning to do therapy suitably called "Cognitive Behavioral Therapy." It is a common yet fascinating aspect of human behavior. Over time, and many personal and professional transformations later, the cognitive behavioral model of change emerged and evolved.

Writing an introduction is, perhaps, an author's most personal statement. It is a frame through which we hope the reader will view and interpret what we offer, and it is a final attempt, placed paradoxically at the beginning, to influence how one's thoughts and, in the case of cognitive behavioral theory, one's clinical work will be received.

A write this introduction at the end of my journey, aware that it is only as I myself emerge from my embeddedness in this dissertation that I can hope to gain some perspective from which to view it.

Rationale

The client selected for this dissertation study is a 43-year-old single parent. This client was selected for the following areas of clinical interest: (a) her self-esteem, depression, and anxiety issues; (b) her continuing difficulties in romantic relationships with men; and - her fight with obesity from an eating disorder.

Chapter Two: Review of the Relevant Literature

Background and Overview. Clinical depression can occur in a variety of forms; the three primary types are known as major depression (or unipolar depression), dysthymia, and bipolar disorder (or manic depression). According to Myslinski (2004), "Taken together, they appear to be the most common group of mental health problems in the world, affecting people of every race, culture, and ethnicity. While a small percentage of children are affected, the elderly are much more vulnerable" (p. 150). Generally speaking, the lifetime prevalence of all types of mood disorders in the United States has been estimated to be 17% by recent epidemiological studies and current prevalence estimates range from 4.6 to 10.3% (Kessler et al., 1994). Furthermore, a number of trends suggest that the rates of depression may be on the rise (Bernal, Hargreaves & Miller et al., 1995; Austrian, 2000). Recent findings show that depressive symptoms, with or without depressive disorder, can impair functioning and well-being to levels comparable with or worse than chronic medical conditions such as hypertension, diabetes, angina, arthritis, back problems, lung problems, and gastrointestinal disorders (Bernal, Hargreaves & Miller et al.,...

While there have been some significant advances in the treatment of depression, a number of problems remain; for instance, less than 20% of individuals who meet the criteria for affective disorders seek treatment from mental health specialists and between 20 and 50% of those who begin psychiatric treatment in controlled trials terminate their participation prematurely (Bernal, Hargreaves & Miller et al., 1995). Finally, only about 40% of those completing treatment remain relatively free of symptoms one year following treatment (Bernal, Hargreaves & Miller et al., 1995). Based on the high prevalence of depression and existing constraints to efficacious treatment approaches, more research is clearly needed to develop methods to prevent and treat depressive disorders.
Depression in General. Despite some significant progress in the conceptualization of depression over the past two decades, much remains unclear concerning its incidence and etiology. The typical measures used in past studies are heterogenous, varying from self-reports to diagnostic interviews; further, the term "depression" connotes a wide range of meanings depending on the setting (Marcotte, Fortin, Povtin et al., 2002). The depressive syndrome is defined by Marcotte et al. As a combination of symptoms that are frequently found together that affect functioning of the individual in the cognitive, behavioral, affective, and somatic domains. Table 1 below sets forth the DSM-IV Diagnostic Criteria for Major Depressive Episode (296.xx):

Table 1. DSM-IV Diagnostic Criteria for Major Depressive Episode.

A. Five (or more) of the following symptoms have been present nearly every day during the same two-weeks period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1) depressed mood most of the day

2) markedly diminished interest or pleasure in (almost) all activities most of the day

3) significant weight loss, when not dieting, or weight gain (e.g., more than 5% of body weight in a month); or decrease or increase in appetite

4) insomnia or hypersomnia

5) psychomotor agitation or retardation (observable by others)

6) fatigue or less of energy

7) feelings of worthlessness or inappropriate guilt

8) diminished ability to think or concentrate, or indecisiveness

9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, a specific suicide plan, or suicide attempt

B. The symptoms do not meet criteria for a mixed mood episode.

C. The symptoms cause clinically significant distress, or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance e.g., drugs abuse, medication) or general medical condition.

E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for more than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation (Adapted from DSM-IV).

Studies have also shown that there is high co-morbidity between depression and substance abuse. It has been suggested that, "the rates of depression in drug-using populations exceed those in the general population" (McBride et al., 2000, p. 71). The co-morbidity relationship between depression and substance use disorders is typically attributed to a causal relationship or an etiological factor that may be shared by both disorders; for instance, Swendsen and Merikangas (2000) write that "the association of alcoholism with depression is likely to be attributable to causal factors rather than a shared etiology, but the scarcity of information for other classes of substance use disorders precludes similar conclusions regarding their association with depression" (p. 173).

Dysthymia: Definitions and Discussion. Dysthymia is a hybrid construct which combines elements of the descriptive and psychodynamic literatures on neurotic depression, the depressive temperament; personality, and chronic depression (Klein, 1991). While generally presumed to be a mild form of mood disorder, the DSM -- III (American Psychiatric Association, 1980) and DSM--III -- R criteria for dysthymia identify a relatively severe condition (Klein, 1991). People with dysthymia generally suffer from low-grade but chronic depression that can last for years and, like cyclothymia, may be mistakenly seen as characterological. According to Austrian, "These people frequently say they do not remember a time when they were not depressed, yet they may function relatively well outside of interpersonal relationships. The initial onset may be insidious. Without intervention, this milder depression will persist" (Austrian, 2000, p. 37). Dysthymia may be preceded, and later follow, an episode of major depression; it is during this period that interventions will most likely be sought. Dysthymia can be more persistent but less severe than major depression; there is often a poorer level of baseline functioning, and there is a poorer prognosis; if dysthymia and major depression coexist ("double depression"), the prognosis is even more grim (Austrian, 2000).

According to Austrian (2000), dysthymia (formerly known as "neurotic depression") is a term that is derived from the Greek for "ill humor" or "a bad state of mind;" the author notes that "It is a milder, more chronic depressive disorder: an individual is not free of symptoms for more than two months in a period of at least two years. It is insidious, chronic, lingering, and often misunderstood, misdiagnosed, and mistreated" (p. 34). Unfortunately, there remains a paucity of information about dysthymia and its relationship to the factors that generally contribute to depressive disorders; Crosby,…