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Diagnostic Criteria for Major Depressive Disorder and Depressive Episodes DSM-V

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Antidepressants are psychiatric medications given to patients with depressive disorders to alleviate symptoms. They correct chemical imbalances of neurotransmitters in the brain which probably cause changes in mood and behavior.

Antidepressants may be used for a wide range of psychiatric conditions, including ssocial anxiety disorder, anxiety disorders, and dysthymia (mild chronic depression).

Antidepressants were initially developed in the 1950s. Their use has become progressively more common over the last twenty years.

Antidepressant usage is increasing

In 1996 there were 13.3 million people using antidepressants in the United States. By 2010, the figure stood at 23.3 million people. Researchers from Columbia University Medical Center, the New York State Psychiatric Institute, and the University of Pennsylvania added that rates remained low among racial and ethnic minorities.

They believe antidepressant usage has become more common because:

There has been a broadening in the concepts of need for mental health treatment

Campaigns to promote mental health care have become more widespread

Mental health treatments have become more widely accepted by the public

The Centers for Disease Control and Prevention ¹ (CDC) reported that antidepressant usage in the USA among people aged 12 or more years rose by 400% between 1988-1994 and 2005-2008.
According to data gathered from public health authorities in Canada, Western Europe and Australasia, increased antidepressant usage has been a progressively common trend in most industrialized countries.

How do antidepressants work?

This YouTube video by Paul Bogdan explains how antidepressants work.

Types of antidepressants

According to the Royal College of Psychiatrists ², England, there are nearly thirty different kinds of antidepressants, which can be divided into five main types:

1) Monoamine oxidase inhibitors (MAOIs)

Also known as monoamine oxidase inhibitors, are a kind of antidepressant that inhibit the action of monoamine oxidase, a brain enzyme. Monoamine oxidase helps break down neurotransmitters, such as serotonin.

If less serotonin is broken down, the patient hopefully has more stabilized moods and less anxiety. Doctors usually use MAOIs if SSRIs have not worked, because MAOIs clash with a considerable number of other medications and some foods.

MAOIs have the following possible side effects: blurred vision, rash, seizures, edema, weight loss, weight gain, sexual dysfunction, diarrhea, nausea, constipation, anxiety, insomnia, drowsiness, headache, dizziness, arrhythmia, fainting, feeling faint when standing up (postural hypotension), and hypertension.

Examples of Monoamine Oxidase Inhibitors are: phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan) and selegiline (EMSAM, Eldepryl).

2) Noradrenaline and Specific Serotoninergic Antidepressants (NASSAs)

These are a class of compounds which are used in the treatment of anxiety disorders, some personality disorders, and depression.

NASSAs have the following possible side effects: constipation, dry mouth, weight gain, drowsiness, sedation, blurred vision and dizziness. More serious adverse reactions include: seizures, white blood cell reduction, fainting, and allergic reactions.

Examples of Noradrenaline and Specific Serotoninergic Antidepressants include: Mianserin (Tolvon) and Mirtazapine (Remeron, Avanza, Zispin)

3) Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs)

SNRIs are a class of drugs used to treat major depression, mood disorders, and possibly but less commonly ADHD (attention deficit hyperactivity disorder), obsessive compulsive disorder, anxiety disorders, menopausal symptoms, fibromyalgia, and chronic neuropathic pain.

SNRIs raise levels of serotonin and norepinephrine, two neurotransmitters in the brain - they both play a key role in stabilizing mood. (See below in side effects for SSRIs, which are very similar)

Examples of Serotonin Norepinephrine Reuptake Inhibitors are: duloxetine (Cymbalta), venlafaxine (Effexor) and desvenlafaxine (Pristiq).

4) Selective Serotonin Reuptake Inhibitors (SSRIs)

Prozac (fluoxetine) is probably the most widely known antidepressant worldwide among lay people.

SSRIs are the most commonly prescribed antidepressants. Experts say that SSRIs are not only very effective in treating depression; they also have fewer side-effects than the other types.

SSRIs block the reuptake (absorption) of serotonin in the brain, thus helping the brain cells receive and send messages, which results in better and more stable moods. They are called "selective" because they seem to mainly affect serotonin, and not the other neurotransmitters.

SSRIs and SNRIs may have the following side effects: hypoglycemia, low sodium, nausea, rash, dry mouth, constipation, diarrhea, weight loss, sweating, tremor, sedation, sexual dysfunction, insomnia, headache, dizziness, anxiety, agitation, and abnormal thinking.

Examples of SSRI antidepressants are: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil) and sertraline (Zoloft)

5) Tricyclics

Tricyclics are so named because there are three rings in the chemical structure of these medications. This class of medication is used to treat depression, and also some types of anxiety, fibromyalgia, and to control chronic pain.

Tricyclics may have the following side effects: seizures, insomnia, anxiety, arrhythmia, hypertension, rash, nausea, vomiting, abdominal cramps, weight loss, constipation, urinary retention, increased pressure on the eye, and sexual dysfunction.

Examples of tricyclic antidepressants are: amitriptyline (Elavil), amoxapine- clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil) and trimipramine (Surmontil)

Antidepressants are not all the same

How the antidepressants affect neurotransmitters, how they are used, and what adverse effects or drug interactions are associated with them differ. One patient may not respond to one type of antidepressant and do better with another, while another person with a similar condition might respond the other way round.

Most antidepressants take a while to work

Most antidepressants take a few weeks to work. They are usually taken for a few months or several years.

Lack of compliance is a serious problem in getting the best out of antidepressants. Compliance means sticking to the treatment regime, taking the tablets at the same time every day, not forgetting to take them, etc. Patients with depression may not like having to wait several weeks for a result, and many drop out before the medication has had a chance to work.

Antidepressants are used to treat several conditions and illnesses

Despite the name - antidepressants - these medications can be used to treat several different types of illnesses and conditions, and not all of them psychiatric ones.
Primary (approved) uses of antidepressants are for the treatments of: Some "off-label" uses of antidepressant (for an unapproved indication) include:
Antidepressants were ineffective for treating repetitive behaviors in children with autism, researchers from Yale University School of Nursing and the Child Study Center, found.

How effective are antidepressants?

According to the Royal College of Psychiatrists ², the percentage of people who reported a significant improvement after three taking an antidepressant for three months were:

50% to 60% of those taking an antidepressant

25% to 30% of those given a placebo (dummy drug)

For a medication to be assessed properly there has to be a clinical trial, preferably a double-blind one, comparing the drug with either another one or a placebo. "Double-blind" means that neither the doctor nor the patient knows who is having the drug and who is having the placebo.

Placebos do have an effect on improving symptoms in many illnesses and conditions; we call this the "placebo effect". For a drug to be considered for approval by a country's regulatory authorities there needs to be a "significant difference" between the active ingredient (drug) and the placebo. In this case, 50%-60% is significantly different from 25%-30%.

Researchers from the Northwestern University Feinberg School of Medicine believe that about half of all patients never get relief from antidepressants because their illness has been oversimplified and their medication is aimed at the wrong target. Professor Eva Redei explained that antidepressants are often targeting and treating stress, rather than the depression itself.

Medication plus psychotherapy is more effective - patients who receive a combination of antidepressant medication and psychotherapy tend to get better results with major depressive disorder compared to those who are on medication alone or have just psychotherapy, according to several studies.

A team from the National Institutes of Health's National Institute of Mental Health reported in Archives of General Psychiatry that adolescents with major depression who received a combination of medication and psychotherapy over a 36-week period had significantly superior improvements than patients of the same age who were receiving just one type of therapy. They noted that a higher percentage (15%) of those on fluoxetine (Prozac) alone had suicidal thoughts than those on cognitive behavioral therapy alone (6%) or combination treatment (8%).

Can I become addicted to an antidepressant?

Unlike nicotine, some illegal street drugs, tranquilizers and many painkillers, you do not need to keep raising the dose to get the same effect with antidepressants - so in that sense they are not addictive.

When somebody is weaned off an antidepressant they will not experience the withdrawal symptoms that you get when you are addicted to nicotine and try to give up smoking.

However, studies have shown that nearly one third of all patients on SSRIs and SNRIs experienced withdrawal symptoms when treatment stopped. Withdrawal symptoms lasted from two weeks to a couple of months.

Withdrawal symptoms reported included anxiety, dizziness, nightmares and/or vivid dreams, electric shock-like sensations in the body, flu-like symptoms, and stomachache. In the vast majority of cases, symptoms were mild. Severe cases are uncommon and are more likely to happen when patients come off Seroxat and Efexor. Doctors should wean patients off antidepressants gradually to minimize the risk of unpleasant withdrawal symptoms.

Is it withdrawal or illness recurrence? - If a patient finds it hard to cope some months after stopping antidepressant therapy, it is probably because their original illness or condition has come back, rather than a withdrawal problem.

SANE ⁵ in Australia explains that antidepressants change the way you feel. "This means that if you stop taking the medication you may start to feel the way you did before the treatment. Some people confuse this with being addicted. Antidepressants are not addictive and you will not become dependent on them."

Can pregnant women take antidepressants?

The doctor and patient need to discuss fully the benefits and potential harms of coming off antidepressants during pregnancy. Some people really need the medication to be well. Ideally, a pregnant mother should take as little medication as possible.

The mother and doctor need to consider what the effect on the child would be if she came off the drug and became very ill. Other therapies should be discussed and considered, such as CBT (cognitive behavioral therapy), meditation, or yoga.

Risk of miscarriage - a team of medical investigators and pharmacists from the University of Montreal reported in CMAJ (Canadian Medical Association Journal) that taking antidepressants during pregnancy raises the risk of miscarriage by 68%. They added that up 3.7% of pregnant mothers use antidepressants during their first trimester.

High blood pressure - scientists from the University of Montreal, Quebec, Canada, reported in the British Journal of Clinical Pharmacology that using selective serotonin re-uptake inhibitors during pregnancy most likely raises the risk of pregnancy-induced hypertension ( high blood pressure). The authors added that they had not established a causal link

Neonatal abstinence syndrome - a study at the Children's Medical Center of Israel, Petah Tiqwa, found that almost one third of infants whose mothers were on antidepressants while pregnant went through neonatal abstinence syndrome; withdrawal symptoms that include disturbed sleep, tremors and high-pitched crying. In some cases, their symptoms were severe.

A study using laboratory rats which were exposed to an antidepressant just before and after birth, found that they had considerable brain abnormalities and behaviors. The animals had been exposed to citalopram, a serotonin-selective reuptake inhibitor.

Can I take antidepressants if I am breastfeeding?

Some antidepressants get into the breast milk in only tiny amounts; examples include sertraline and nortriptyline. Within a few weeks after birth the livers and kidneys of babies are able to break down the medication's active ingredients effectively, as well as adults do.

The mother and doctor need to consider several factors:

The general health of the baby, is he/she premature, for example

The risk of the mother's mental condition returning

How much of the active ingredients gets into the breast milk (this varies, depending on the drug)

The Journal of Clinical Endocrinology & Metabolism published a study which found that antidepressant usage during pregnancy may delay lactation after childbirth; in other words, it may take longer for the mothers to be able to breastfeed. Mothers may need additional support to be able to successfully breastfeed. Co-author, Nelson Horseman, PhD, said "The breasts are serotonin-regulated glands, meaning the breasts' ability to secrete milk at the right time is closely related to the body's production and regulation of the hormone serotonin."

Taking antidepressants requires compliance, close monitoring and some perseverance

A sizeable minority of patients, between 40% and 50% of them, say their medications were not effective, even after having taken them for three months. There could be many reasons for this; possibly the wrong medication was chosen, the patient was not closely monitored enough, the treatment should have included other therapies, such as cognitive behavioral therapy, or poor compliance/adherence (the patient sometimes forgot to take his/her meds, did not take them at the right time, etc).

Keeping in close contact with the doctor helps improve your chances. Possibly the dosage needs to be changed, or the doctor may eventually recommend switching to another medication. This will not happen if the patient does not go back to the doctor.

If there are going to be side effects, they will nearly always be present during the first couple of weeks, and then will gradually wear off. Patients should persevere, unless the side effects are too unpleasant. If this occurs, you should tell your doctor straight away.

The antidepressant needs to be taken according to instructions - if it says every day, it has to be every day, otherwise it will not be effective.

The majority of patients will feel no benefits during the first or second week. The full effect will not be present until after one or two months. Perseverance is vital.

Switch drugs or add another one - researchers from the University of Texas Southwestern Medical Center said that if your antidepressant is not working within six to eight weeks, your chances of recovery are considerably better if you either switch drugs or add another medication, compared to just giving up.

Most American pediatric patients do not complete their course - approximately half of all Medicaid-covered children and adolescents in Ohio do not complete their first three months of depression treatment, researchers from Ohio State University found. The authors added that non-compliance was greater among the teenagers.

Primary care physicians and psychiatrists say that the main reason people do not get better and their depression either returns or does not improve is that they stop too early, before any real benefits may be felt.

How long does an antidepressant treatment course last?

The Royal College of Psychiatry says that the majority of depressions resolve within about 8 months without treatment. People who stop taking their medication before 8 months risk a return of symptoms. Ideally, the patient should stay on the antidepressant for at least six months after feeling better. Patients who have had at least two attacks should carry on with the treatment for at least 24 months.

In more severe cases, when the depression regularly recurs, they may have to continue with their pharmacological treatment for several years.

Long-term antidepressant usage may worsen depression outcome - scientists from the University of Bologna, Italy, found that sometimes, long-term usage of antidepressants may make the person biochemically more vulnerable to depression. They added that in many cases there will be a poor response to pharmacological treatment.

Reducing the risk of the depression coming back

Some studies have shown that a healthy, well-balanced diet, plenty of exercise, and staying in touch with family and friends can reduce the risk of depression.

Disappointing findings regarding exercise and depression - a published in the BMJ (British Medical Journal) found that there was no difference in outcomes between depressed people who received "usual care" and those who received "usual care plus exercise".

People with mild depression may benefit from counseling.

Hypericum, which is made from St. John's wort, a herb, has been shown to help a number people with depression.

The National Center for Complementary and Alternative Medicine ³, part of the US National Institutes of Health, says that St. John's wort may help some types of depression. However, it also warns that combining St. John's wort with certain antidepressants raises the risk of potentially life-threatening increases in serotonin. There is also the risk that the herb might reduce the efficacy of some prescription medications. It is important to tell your doctor or pharmacist if you plan on taking St. John's wort.

For those who suffer from SAD (seasonal affective disorder), sometimes known as "winter blues", a light box may help. The light box is switched on for a specific period each day and the patient sits in front of it. SAD is said affect some adults and teenagers during the winter months because of a lack of sunlight. Plenty of sunlight exposure helps maintain healthy levels of vitamin D. A study found that women with depression who were treated for vitamin D deficiency responded well and reported fewer depressive symptoms.

The US National Library of Medicine ⁴ warns that the light box is not effective for about half of all SAD sufferers.

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What Are Antidepressants? How Do Antidepressants Work?

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Antidepressants are psychiatric medications given to patients with depressive disorders to alleviate symptoms. They correct chemical imbalances of neurotransmitters in the brain which probably cause changes in mood and behavior. Antidepressants may be used for a wide range of psychiatric conditions, including ssocial anxiety disorder, anxiety disorders, and dysthymia (mild chronic depression).

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Summary of Beck's Cognitive Theory

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Evaluation of Biological Approaches to treatment

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Evaluation of Biological Approaches to treatment

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Biological Approaches to treatment Evaluation

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CounsellingResource.com: Psychology, Therapy & Mental Health Resources

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Cognitive therapy (or cognitive behavioural therapy) helps the client to uncover and alter distortions of thought or perceptions which may be causing or prolonging psychological distress.

Underlying Theory of Cognitive Therapy

The central insight of cognitive therapy as originally formulated over three decades ago is that thoughts mediate between stimuli, such as external events, and emotions. As in the figure below, a stimulus elicits a thought - which might be an evaluative judgement of some kind - which in turn gives rise to an emotion. In other words, it is not the stimulus itself which somehow elicits an emotional response directly, but our evaluation of or thought about that stimulus. (Some practitioners use Ellis's ABC model, described on our page about rational emotive behaviour therapy, to describe the role of thoughts or attitudes mediating between events and our emotional responses.) Two ancillary assumptions underpin the approach of the cognitive therapist: 1) the client is capable of becoming aware of his or her own thoughts and of changing them, and 2) sometimes the thoughts elicited by stimuli distort or otherwise fail to reflect reality accurately.

A common 'everyday example' of alternative thoughts or beliefs about the same experience and their resulting emotions might be the case of an individual being turned down for a job. She might believe that she was passed over for the job because she was fundamentally incompetent. In that case, she might well become depressed, and she might be less likely to apply for similar jobs in the future. If, on the other hand, she believed that she was passed over because the field of candidates was exceptionally strong, she might feel disappointed but not depressed, and the experience probably wouldn't dissuade her from applying for other similar jobs.

Cognitive therapy suggests that psychological distress is caused by distorted thoughts about stimuli giving rise to distressed emotions. The theory is particularly well developed (and empirically supported) in the case of depression, where clients frequently experience unduly negative thoughts which arise automatically even in response to stimuli which might otherwise be experienced as positive. For instance, a depressed client hearing "please stop talking in class" might think "everything I do is wrong; there is no point in even trying". The same client might hear "you've received top marks on your essay" and think "that was a fluke; I won't ever get a mark like that again", or he might hear "you've really improved over the last term" and think "I was really abysmal at the start of term". Any of these thoughts could lead to feelings of hopelessness or reduced self esteem, maintaining or worsening the individual's depression.

Usually cognitive therapeutic work is informed by an awareness of the role of the client's behaviour as well (thus the term cognitive behavioural therapy, or CBT). The task of cognitive therapy or CBT is partly to understand how the three components of emotions, behaviours and thoughts interrelate, and how they may be influenced by external stimuli - including events which may have occurred early in the client's life.

Therapeutic Approach of Cognitive or Cognitive Behavioural Therapy

Cognitive therapy aims to help the client to become aware of thought distortions which are causing psychological distress, and of behavioural patterns which are reinforcing it, and to correct them. The objective is not to correct every distortion in a client's entire outlook - and after all, virtually everyone distorts reality in many ways - just those which may be at the root of distress. The therapist will make every effort to understand experiences from the client's point of view, and the client and therapist will work collaboratively with an empirical spirit, like scientists, exploring the client's thoughts, assumptions and inferences. The therapist helps the client learn to test these by checking them against reality and against other assumptions.
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Often this process will continue outside the therapeutic session. For instance, a client whose fear of dying in a car crash is causing them great anxiety when it comes time to drive to work might record on a slip of paper their estimate of the odds of dying in a car crash at various points in the morning - when they first get up, when they are nearly ready to leave the house, when they are almost to the car, and when they are actually driving. (For someone experiencing such anxiety, these odds might go something like: 1,000 to 1 against when first getting up; 20 to 1 against when nearly ready to leave the house; 2 to 1 against when almost to the car; 5 to 1 in favour of dying in a car crash when actually driving.) This can help the client to see that their estimated odds of actually dying in a car crash are changing just as they move about the house and complete the morning routine. This can be the first step toward making those estimates more realistic and reducing the anxiety which accompanies the thought that one is very likely to die in a crash while driving.

Because of the interrelationship between thoughts, feelings and behaviours, therapeutic interventions frequently involve the client's behaviour. For instance, a client with a strong fear that squirrels will jump onto their head if they walk under trees may go to great lengths to avoid walking under trees. This behaviour will prevent the client from acquiring information that contradicts their thought that "if I walk under a tree, a squirrel will jump onto my head" or perhaps their mental image of a squirrel jumping onto their head the moment they step under a tree. The therapist may help the client to overcome this avoidance of walking under trees as part of the process of correcting the distorted thought that walking under trees will lead to squirrels jumping on the client's head.

Throughout this process of learning, exploring and testing, the client acquires coping strategies as well as improved skills of awareness, introspection and evaluation. This enables them to manage the process on their own in the future, reducing their reliance on the therapist and reducing the likelihood of experiencing a relapse.

Criticisms of Cognitive Therapy and CBT

On first hearing of the basic cognitive therapeutic approach, many people will observe that simply being told that a view doesn't accurately reflect reality doesn't actually make them feel any better. They might say, "I know squirrels aren't likely to jump on my head, but I can't help worrying about it anyway". But to suggest that a cognitive therapist merely tells the client something is wrong is to caricature the approach (and, in fact, few cognitive therapists would actually tell a client some view doesn't reflect reality anyway; they would help the client to explore whether it reflects reality). This would be like criticising the person-centred approach on the grounds that a therapist merely telling a client they are free to discuss anything they like, without judgement from the therapist, doesn't make it feel any easier to talk about difficult problems.

A more salient criticism for some clients may be that the therapist initially may fulfil something of an authority role, in the sense that they provide problem solving experience or expertise in cognitive psychology. Some people may also feel that the therapist can be 'leading' in their questioning and somewhat directive in terms of their recommendations.

Best Fit With Clients

Clients who are comfortable with introspection, who readily adopt the scientific method for exploring their own psychology, and who place credence in the basic theoretical approach of cognitive therapy, may find this approach a good match. Clients who are less comfortable with any of these, or whose distress is of a more general interpersonal nature - such that it cannot easily be framed in terms of an interplay between thoughts, emotions and behaviours within a given environment - may be less well served by cognitive therapy. Cognitive and cognitive-behavioural therapies have often proved especially helpful to clients suffering from depression, anxiety, panic and obsessive-compulsive disorder.

Further Reading on Cognitive Therapy

Our annotated bibliography includes pointers to additional reading on this and other therapeutic approaches. The basic cognitive therapy framework is explained well by Beck (1976), and Trower, et al (1988) offer a good introduction to the modern cognitive behavioural approach.

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Cognitive therapy (or cognitive behavioural therapy) helps the client to uncover and alter distortions of thought or perceptions which may be causing or prolonging psychological distress. The central insight of cognitive therapy as originally formulated over three decades ago is that thoughts mediate between stimuli, such as external events, and emotions.

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CounsellingResource.com: Psychology, Therapy & Mental Health Resources

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Rational emotive behaviour therapy focuses on uncovering irrational beliefs which may lead to unhealthy negative emotions and replacing them with more productive rational alternatives.

Underlying Theory of Rational Emotive Behaviour Therapy

Rational emotive behaviour therapy ('REBT') views human beings as 'responsibly hedonistic' in the sense that they strive to remain alive and to achieve some degree of happiness. However, it also holds that humans are prone to adopting irrational beliefs and behaviours which stand in the way of their achieving their goals and purposes. Often, these irrational attitudes or philosophies take the form of extreme or dogmatic 'musts', 'shoulds', or 'oughts'; they contrast with rational and flexible desires, wishes, preferences and wants. The presence of extreme philosophies can make all the difference between healthy negative emotions (such as sadness or regret or concern) and unhealthy negative emotions (such as depression or guilt or anxiety). For example, one person's philosophy after experiencing a loss might take the form: "It is unfortunate that this loss has occurred, although there is no actual reason why it should not have occurred. It is sad that it has happened, but it is not awful, and I can continue to function." Another's might take the form: "This absolutely should not have happened, and it is horrific that it did. These circumstances are now intolerable, and I cannot continue to function." The first person's response is apt to lead to sadness, while the second person may be well on their way to depression. Most importantly of all, REBT maintains that individuals have it within their power to change their beliefs and philosophies profoundly, and thereby to change radically their state of psychological health.

REBT employs the 'ABC framework' - depicted in the figure below - to clarify the relationship between activating events (A); our beliefs about them (B); and the cognitive, emotional or behavioural consequences of our beliefs (C). The ABC model is also used in some renditions of cognitive therapy or cognitive behavioural therapy, where it is also applied to clarify the role of mental activities or predispositions in mediating between experiences and emotional responses.

The figure below shows how the framework distinguishes between the effects of rational beliefs about negative events, which give rise to healthy negative emotions, and the effects of irrational beliefs about negative events, which lead to unhealthy negative emotions.

In addition to the ABC framework, REBT also employs three primary insights:

1. While external events are of undoubted influence, psychological disturbance is largely a matter of personal choice in the sense that individuals consciously or unconsciously select both rational beliefs and irrational beliefs at (B) when negative events occur at (A)

2. Past history and present life conditions strongly affect the person, but they do not, in and of themselves, disturb the person; rather, it is the individual's responses which disturb them, and it is again a matter of individual choice whether to maintain the philosophies at (B) which cause disturbance.

3. Modifying the philosophies at (B) requires persistence and hard work, but it can be done.

Therapeutic Approach of Rational Emotive Behaviour Therapy

The main purpose of REBT is to help clients to replace absolutist philosophies, full of 'musts' and 'shoulds', with more flexible ones; part of this includes learning to accept that all human beings (including themselves) are fallible and learning to increase their tolerance for frustration while aiming to achieve their goals. Although emphasizing the same 'core conditions' as person-centred counselling - namely, empathy, unconditional positive regard, and counsellor genuineness - in the counselling relationship, REBT views these conditions as neither necessary nor sufficient for therapeutic change to occur.

The basic process of change which REBT attempts to foster begins with the client acknowledging the existence of a problem and identifying any 'meta-disturbances' about that problem (i.e., problems about the problem, such as feeling guilty about being depressed). The client then identifies the underlying irrational belief which caused the original problem and comes to understand both why it is irrational and why a rational alternative would be preferable. The client challenges their irrational belief and employs a variety of cognitive, behavioural, emotive and imagery techniques to strengthen their conviction in a rational alternative. (For example, rational emotive imagery, or REI, helps clients practice changing unhealthy negative emotions into healthy ones at (C) while imagining the negative event at (A), as a way of changing their underlying philosophy at (B); this is designed to help clients move from an intellectual insight about which of their beliefs are rational and which irrational to a stronger 'gut' instinct about the same.) They identify impediments to progress and overcome them, and they work continuously to consolidate their gains and to prevent relapse.
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To further this process, REBT advocates 'selective eclecticism', which means that REBT counsellors are encouraged to make use of techniques from other approaches, while still working specifically within the theoretical framework of REBT. In other words, REBT maintains theoretical coherence while pragmatically employing techniques that work.

Throughout, the counsellor may take a very directive role, actively disputing the client's irrational beliefs, agreeing homework assignments which help the client to overcome their irrational beliefs, and in general 'pushing' the client to challenge themselves and to accept the discomfort which may accompany the change process.

Criticisms of Rational Emotive Behaviour Therapy

As one leading proponent of REBT has indicated, REBT is easy to practise poorly, and it is from this that one immediate criticism suggests itself from the perspective of someone who takes a philosophical approach to life anyway: inelegant REBT could be profoundly irritating! The kind of conceptual disputing favoured by REBT could easily meander off track into minutiae relatively far removed from the client's central concern, and the mental gymnastics required to keep client and therapist on the same track could easily eat up time better spent on more productive activities. The counsellor's and client's estimations of relative importance could diverge rather profoundly, particularly if the client's outlook really does embody significant irrationalities. Having said all that, each of the preceding sentences includes the qualifier ' could ', and with a great deal of skill, each pitfall undoubtedly could be avoided.

Perhaps more importantly, it would appear that the need to match therapeutic approach with client preference is even more pressing with REBT than with many others. In other words, it seems very important to adopt the REBT approach only with clients who truly are suitable, as it otherwise risks being strongly counter-productive. On this point, however, it is crucial to realize that some clients specifically do appreciate exactly this kind of approach, and counsellors who are unable or unwilling to provide the disputation required are probably not right for those clients.

Best Fit With Clients

REBT is much less empirically supported than some other approaches: the requisite studies simply have not been completed yet, and the relevant data points for determining the best match with clients are therefore thin on the ground. However, one may envision clients responding particularly well who are both willing and able to conceptualise their problems within the ABC framework, and who are committed to active participation in the process of identifying and changing irrational beliefs (including performing homework assignments in support of the latter). Clients will also need to be able to work collaboratively with a counsellor who will challenge and dispute with them directly, and a scientific and at least somewhat logical outlook would seem a pre-requisite. REBT would be less suitable for clients who do not meet one or more of the above. And as hinted above in the section on Criticims, one might also speculate that clients who are already highly skilled in philosophical engagement could find the approach less useful. (Perhaps REBT-style self help could be of more benefit for such clients?)

Further Reading on Rational Emotive Behaviour Therapy

Our annotated bibliography includes pointers to additional reading on this and other therapeutic approaches. The comment referenced in the section on Criticisms, on the easiness of practising REBT poorly, is due to Dryden (2002b), p. 367; the notion of 'selective eclecticism' is due to Dryden (1987). Note that REBT is closely related to cognitive therapy and is viewed by many as a subset of it.

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Rational emotive behaviour therapy focuses on uncovering irrational beliefs which may lead to unhealthy negative emotions and replacing them with more productive rational alternatives. Rational emotive behaviour therapy ('REBT') views human beings as 'responsibly hedonistic' in the sense that they strive to remain alive and to achieve some degree of happiness.

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Guidance for Assessment 2 Psychology ESSAY - JESSICA

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GETSELFHELP.co.uk
The CBT therapy and self help resources website. Self help guides, worksheets, videos and downloads.

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An overview of the theory, practice, and research aspects of psychoanalysis. Clinicians discuss the nature of the unconscious, the work of Sigmund Freud, the process of gaining self-awareness and the opportunities for growth using the psychoanalytic approach. Produced by Anne Frances Johnson (www.annefjohnson.com) with support from the North Carolina Psychoanalytic Foundation.

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Welcome to our page on Freud's theory of dreams.

Before embarking on Freud's means of dream analysis, we must first assess what he perceived dreams to be. Essentially in his view, dreams were made up of two principles, Wish Fulfilment, and Manifest v. Latent Content.

Wish Fulfilment

Freud considered dreams to be keyholes into our unconscious mind where the fears, desires and emotions exist that we suppress in some form or another to hide from conscious thought. In other words, we don't want to know about them so they get driven into the recesses of the subconscious. Thus, with respect to the concept of wish- fulfilment and dreaming, we are "wishing" that the thing that concerns us in the subconscious, expressed via the dream, does not happen. Therefore, on this basis, both "negative" and "positive" (things we wish do happen) dreams are the result of wish-fulfilment.

Freud believed that although our dreams were the result of this wish-fulfilment concept, the subconscious does not directly relay the important message. That is, the message is provided in symbolism and must be decoded. Not because the subconscious wants to make things difficult, but due to symbolism being it's only means of communication; the conscious, if you recall, is attempting to bury these desires, instincts, and emotions. Thus, the subconscious is unearthing them in an effort to say, "Hey, this is the true you and your unwillingness to acknowledge as much is causing you problems."

Manifest v. Latent Content

Freud made a differentiation between what we actually dream (manifest content) and the unfulfilled wish that the dream represents (latent content). On this topic Freud offered the following:

"All previous attempts to solve the problems of the dream have been based directly upon the manifest dream content as it is retained in the memory, and have undertaken to obtain an interpretation of the dream from this content.... We alone are in possession of new data; for us a new psychic material intervenes between the dream content and the results of our investigations: and this is the latent emphasis... We develop a solution of the dream from the latter, and not from the manifest dream content. We are also confronted for the first time with a problem which has before existed, that of examining and tracing the relations between the latent dream thoughts and the manifest dream content, and the processes through which the former have grown into the latter."

In Freud's theory of dreams, the content of dreams is hardly ever presented in direct form that requires no coding. Rather, dreams are complex, made up of symbols that best represent the message presented. Think of this as akin to Christmas shopping for a few people. You peruse the items and pick the ones that are suited to each individual. The unconscious does something similar; it selects the symbols from the individual's life that they will best understand. This is then followed by arranging these symbols into a narrative structure that best represents the message.

Often the end production is raw in its truthfulness. Dreams are never sugar-coated or watered down. If the subconscious perceives the timing is right to relay its secret code, it will not hold back. Freud suggested that because of this raw production, our conscious mind attempts to reject the messages in our dreams. In other words, even when the message has been sent, opened, and read (not interpreted); our wakeful mind tries to "repress" this knowledge.

Related Pages

(From Freuds Theory on Dreams back to Freud Dream Interpretation)(From Freuds Theory on Dreams back to Dream Interpretation Dictionary Home Page)

Read, reflect and be inspired. If you find something of value on our Freuds Theory of Dreams page, enjoy its gifts and please pass it on to your friends.

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Freuds Theory on Dreams: What Dreams are Made of

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Welcome to our page on Freud's theory of dreams. Before embarking on Freud's means of dream analysis, we must first assess what he perceived dreams to be. Essentially in his view, dreams were made up of two principles, Wish Fulfilment, and Manifest v. Latent Content.

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Counselling Skills useful to describe and evaluate psychoanalytic methods such as Dream Interpretation

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Gross Chapter useful for description of psychoanalytic methods and some evaluation points.

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Gross Chapter useful for description of psychoanalytic methods and some evaluation points.

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Psychcentral.com

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Over the years many people have questioned whether psychoanalysis really works. It has especially come under attack in recent years, as psychotherapy has become controlled by insurance companies, who bemoan any long-term treatment. Those who practice psychoanalytic psychotherapy have asserted strongly that it works. They point to qualitative improvements in social functioning, self-esteem, work relationships, and other such factors. And there are thousands upon thousands of case histories, written since the time of Sigmund Freud, that testify to its success.

However, the acid test of the efficacy of any method lies in the availability of hard evidence in the form of research. And, as it happens, we have two recent studies of psychoanalysis that offer evidence of its validity.

A study by Shedler in the February-March 2010 edition of the American Psychologist (put out by the American Psychological Association), examined the results of treatments using psychodynamic psychotherapy for a variety of psychological disorders. This was a meta-analysis that covered studies done around the world. It concluded that psychodynamic psychotherapy works as well as, or is at least equivalent to, other psychotherapy treatments deemed as supported by empirical evidence, such as CBT.

Prior to this study there was a meta-analysis of short-term psychodynamic therapy by Leichsenring and colleagues. published in the Archives of General Psychiatry in 2004. This study looked at seventeen random controlled studies of treatment with depression, bulimia, post-traumatic stress disorder, generalized anxiety disorder and various personality disorders. They measured results using the Hamilton depression scale and other such methods and found that symptoms improved when compared to control groups of patients on waiting lists or in non-psychodynamic therapies.

Of course, these days most psychotherapists, including most psychoanalysts, practice eclectic therapy, as no one modality is right for everybody. In my psychotherapy practice over 38 years, I have used behavioral and cognitive therapy as well as psychoanalytic therapy. I sometimes find that all three are needed with the same client, and that all can play an important role.

A person may have ongoing anger at a spouse, who may suffer from some form of depression that causes emotional paralysis and prevents getting a job. It then falls on this healthier individual to take responsibility for the family's income. On a cognitive-behavioral level I encourage the client to focus on the reality of the situation, which is that the spouse cannot look for a job because of the emotional problem, not because "the spouse is lazy."

On a behavioral level I may also discuss the importance of detaching from the anger, noting that it is causing health problems. However, at the same time, on a psychoanalytic level I will focus on the transference-that is, on how unresolved anger at one's father (who had similar anger and paralysis) is now being displaced onto the spouse. All these approaches may be needed to bring about real change.

However, there is one ingredient of psychoanalytic therapy that has been there from the beginning and remains the special feature that makes it a vital form of therapy: the relationship between the client and the psychoanalyst. Clients, by being completely honest about their thoughts and feelings about the psychoanalyst, learn to understand themselves and how they relate to the analyst (and hence others) in an immediate way that goes right to the core of their issues. In doing this, they work through the misinterpretations (cognitive flaws) by being confronted with their immediate effect.

A client once came into treatment who would hardly talk for many weeks. There were long silences during which I would ask, "What are you thinking now?" Eventually the client got around to talking about how her parents had always been on her case as she grew up. In the treatment she was transferring her parents onto me and expecting me to be on her case if she told me too much. She also realized that she related to others in this same way. Thus the psychoanalytic method helped her to resolve some of her deepest issues right from the beginning.

Methods, however, don't do therapy; people do. Methods are only as good as the people who use them. If you can form a good therapeutic alliance with a client, he or she will usually get better, no matter what the method is. If you can't form a good therapeutic alliance, no method will work.

Having said all this, the bottom line is that evidence does exist to support the benefits of psychoanalytic therapy. It does really work when it is done the way it needs to be done and when it is received the way it needs to be received.

As is so often the case, the doubts are not in the method, but in the mind of the beholder.
Tear image available from Shutterstock.

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Does Psychoanalytic Therapy Really Work?

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Over the years many people have questioned whether psychoanalysis really works. It has especially come under attack in recent years, as psychotherapy has become controlled by insurance companies, who bemoan any long-term treatment. Those who practice psychoanalytic psychotherapy have asserted strongly that it works.

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The Efficacy of Psychodynamic Psychotherapy

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The Efficacy of Psychodynamic Psychotherapy

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Marking Grid