CBT and Person-Centered Therapy: Treating Depression

Introduction

The cognitive behavioral and person-centered approaches to counseling and psychotherapy come from markedly different developmental histories and theoretical underpinnings. Cognitive behavioral therapy (CBT) is a psychological approach that addresses problematic behaviors arising from recurrent negative thoughts and has proven useful in treating anxiety, depression, and substance abuse disorders, among others. There are also many psychotherapy practices that can be integrated with counseling strategies to provide a more comprehensive approach to treatment. This paper offers a theoretical background of cognitive behavioral therapy and psychotherapy, applies these foundations to the treatment of depression, and identifies opportunities in which different approaches could be used in conjunction.

The psychoanalytic approach began with Sigmund Freud's theories of human psychology. He identified three primary drivers of an individual's personality: the id, the ego, and the superego. He explained that an individual's behavior reflects how these three psychological forces work together — or, in some cases, fail to work together. These relationships were thought to serve as the basis for human instincts and decision-making in general. The theory of the ego has continued to evolve since Freud's time, and psychoanalysis — the counseling approach Freud pioneered — is still used to help identify these forces in therapy sessions.

Psychoanalytic Foundations

In Freud's original theory, he conceptualized three distinct regions of the mind. The id was conceived as the entirely unconscious region that also functions as a pleasure center seeking immediate gratification. The ego, operating as a secondary process, tries to reconcile the demands of the id with the limitations of both the natural world and the social systems to which the person must adhere. Finally, the superego functions as an ideological voice — what is commonly thought of as the human conscience or "voice of reason." The interactions among these three forces are dynamic; they constantly compete within the mind, producing the individual's personality and the behaviors observable by others.

Freud further suggested that the ego is the mechanism establishing the division between oneself and others, and it is within this division that personality is displayed. The ego acts as a connector between the id and superego, deciding which force will ultimately manifest. The superego thus serves as the primary mechanism representing a person's moral fabric and judgments about right and wrong in different situations. When any of the three forces become unbalanced, a variety of psychological disorders can result.

Freud's (1923) concept of the ego was elegantly defined in its original formulation (Berzoff, Flanagan, & Hertz, 2008):

"In its relation to the id [the ego] is like a person on horseback, who has to hold in check the superior strength of the horse; with this difference, that the rider tries to do so with his own strength while the ego uses borrowed forces. The analogy may be carried a little further. Often a rider, if he is not to be parted from his horse, is obliged to guide it where it wants to go; so in the same way the ego is in the habit of transforming the id's will into action as if it were his own" (p. 25).

According to Freud, the id, ego, and superego are distributed differently across three levels of awareness: the conscious, the preconscious, and the unconscious. The unconscious mind contains thoughts, memories, and desires that are not easily accessible yet greatly influence behavior. Freud also believed that people must successfully pass through five stages of psychosexual development to become healthy, well-adjusted adults. Each phase has an objective that must be accomplished; failure to do so results in fixation at the uncompleted stage, which creates psychological imbalance. The five stages are: oral, anal, phallic, latent, and genital (Cherry, n.d.). Although many of these theories have been largely discredited, there is still considerable value in understanding the theoretical model, and it retains pragmatic benefits in counseling today.

While Freud explained behavior through forces operating beneath conscious awareness, B.F. Skinner approached the issue from an entirely different perspective when developing his behavioral theory. Behaviorism takes a more scientific stance, working under the assumption that psychology should study only observable behavior without further speculation. Skinner believed that anything unobservable was mere speculation and virtually untestable. He therefore excluded subconscious forces such as Freud's id, ego, and superego from his framework. Rather than focusing on internal psychological processes, Skinner concentrated on observable data that required no subjective appraisal. He believed that the reinforcement of behavioral patterns is one of the primary factors shaping personality, largely through external consequences.

Skinner's behavioral theory attempts to explain the development of personality through the accumulation of an individual's experiences via interactions with the environment — a process referred to as learning along the individual's developmental path. To test his theories, Skinner constructed an apparatus (commonly called a "Skinner box") in which he taught animals to receive food by pecking or pressing a bar or light. This work earned him recognition as the father of operant conditioning. Building on Thorndike's law of effect, Skinner introduced the concept of reinforcement: behavior that is reinforced tends to be repeated (strengthened), while behavior that is not reinforced tends to die out or be extinguished (weakened) (McLeod, 2007). Although humans are far more complex, Skinner believed that most human responses are shaped by a similar conditioning process.

Cognitive Behavioral Theory

One accessible illustration of Skinner's principles involves people who play slot machines. They at least resemble the rats pressing levers in a Skinner box. Both are subject to reinforcement on a variable ratio schedule — a reward occurring, on average, every fifth or tenth response — which produces a high and persistent rate of responding. As one commentator noted, the person in a casino is behaving much like the rat or pigeon in the operant conditioning chamber (Sherman, 2010).

Cognitive behavioral theory asserts that different types of reinforcement affect the likelihood that a particular behavior will be repeated. These include positive reinforcement, negative reinforcement, extinction, and punishment. Positive reinforcement involves providing a reward for a desired response, while negative reinforcement works by removing an aversive stimulus. Extinction occurs when reinforcement ceases, causing the response to diminish over time. Punishment introduces an aversive consequence aimed at suppressing an unwanted behavior. Skinner also argued that reinforcement must be delivered immediately — ideally within about half a second — to maximize the effectiveness of conditioning.

There are many different approaches a counselor can take to assist a patient with behavioral problems. Different theoretical models, such as the two outlined above, make major contributions to psychology. However, numerous subsequent models represent something of a bridge between these two poles. Cognitive behavioral theories have attempted to apply reinforcement principles to mental processes in order to promote more rational thinking and decision-making. Another approach with at least some connection to Freud's work is the person-centered model, which postulates that each individual is moving toward self-actualization and can be guided along that path.

The role of the counselor naturally depends on the individual perspective and professional identity the counselor has developed with the patient, among many other factors. Professional identity is dynamic and evolves over time. One qualitative study focused on the development of this professional identity found that conflict resolution was among the most salient influences on how a professional identity forms (Brott & Myers, 2011). This suggests that, beyond theoretical approaches, interpersonal factors also shape the effectiveness of counseling.

One of the most common applications of counseling is the treatment of depression in both children and adults. According to the National Institute of Mental Health (NIH), an estimated 26.2% of Americans ages 18 and older — about one in four adults — suffer from a diagnosable mental disorder in a given year (NIH, n.d.). The most common treatment methods in advanced countries include psychotherapy, counseling, medication, or some combination of these three. The rates of depression have grown considerably over the past few decades, particularly in industrialized countries. The lifetime risk of developing a depressive episode now approaches 15%, and the World Health Organization ranks depression as the world's fourth greatest public health problem.

Conclusion

It was also found that the effectiveness of counseling and psychotherapy depends heavily on the quality of the counselor-patient relationship and the counselor's interpersonal skills. This relational factor may ultimately be more important than the theoretical orientation employed, and further research should be conducted to better understand its role in treatment outcomes.