1. Thorough Assessment: The treatment of depression relies primarily on an accurate assessment of the symptoms and a case formulation of the exact elements. During the first online interview, John or Sylvia will ask questions about your mood, times when mood improves, or the opposite, suicidal ideation, avoidance of situations or people, behaviours which make you feel safe or inside your safety zone, motivation for change, previous treatments for the problem as well as your expectations and goals of therapy.
2. Behavioural Activation (BA) is used to increase positive reinforcement and reduce avoidance by making the person become more active and functional. This component may or may not be present in your treatment. Sometimes a more cognitive approach is recommended. At other times, a behavioural approach, such as Behavioural Activation is preferred. On occasion, the combination of both will achieve the best outcome. Following the assessment, your CBT therapist will be able to tell you whether you may benefit from one of these components. Both Cognitive and Behavioural interventions are equally effective for depression.
Behavioural Activation incorporates different elements. For example, we ask clients to monitor all the activities they perform during the day. Ideally, clients should schedule and plan in advance, hour by hour, all the activities they could perform in order to maximise their level of achievement and satisfaction with the task. If this is not possible, or clients fail to do what they schedule, they can just record what they do every day, hour by hour, by taking note of the activity and the associated levels of satisfaction and achievement.
Another component of Behavioural Activation involves "Graded Task Assignments". Activities which need to be improved in frequency can be broken down into more manageable steps until the person succeeds in achieving that goal.
3. Examining the validity of thoughts and beliefs (Socratic Questioning):
As the CBT treatment continues, one essential component is examining your beliefs from many different perspectives until you are able to gain insight into the situation that may be more realistic and less dysfunctional. Sylvia or John will help gather evidence in favour of or against your beliefs by looking at the logic of your thoughts or assumptions. This process involving the modification of your beliefs is normally referred to as Socratic Questioning.
4. Assertiveness Training and Social Skills Training.
People suffering from depression are likely to be unassertive. When you have lost confidence in yourself, you may not be using your social skills in ways that are beneficial. In CBT, this is an important component since it helps you regain a sense of control and the ability to deal with others in a brief period of time. The result of becoming more assertive is normally a decrease in depression, an increase in confidence and a perception of self-worth.
John and Sylvia tend to include assertiveness training in their online sessions with depressed clients at some point during the therapy because, in addition to making them feel more confident or less worried in social domains, it also serves to prevent relapses. If clients do not learn how to deal with making or rejecting requests, giving or accepting criticism, respecting their own human rights, or dealing with conflictive situations, some situations they may face could activate schemas of inadequacy, defectiveness, or undesirability and get depressed again.
Moreover, being unassertive makes people more likely to hold resentment because they may have problems expressing dislike or giving/accepting criticism. Therefore, they may feel misunderstood, criticised, and/or rejected. These negative feelings may cause them to ruminate excessively and return to a depressed state. If this is your case, you will learn with online therapy how to leave behind these unhealthy emotions and patterns of thinking.
5. Anti-depressive medication
When people have severe depression, it is advisable to combine online CBT with medication. Some antidepressants will be more appropriate for specific clients than others. For example, some antidepressants contain anti-anxiety components and some do not. CBT works best in combination with antidepressants and prevents further relapses more often than CBT alone. This is true of clients with severe depression (BDI>30). Only general practitioners and psychiatrists can prescribe drugs. However, John and Sylvia can recommend a specific medication because they are well versed in psychotropic drugs.
6. Behavioural Experiments
Finally, another important intervention for depression is the use of behavioural experiments. The objective of this technique is to test dysfunctional beliefs in order to promote a more adaptive way of thinking. Sylvia or John will assess the predictions, assumptions or inferences you hold about a specific situation. Then, an experiment is carefully designed to test those predictions and gain insight about the validity of those beliefs.
Behavioural experiments can also be designed in order to make a client stop using their safety behaviours or reduce avoidance associated with pleasurable activities. Reducing or eliminating avoidance is important as this may have a positive impact on levels of depression by allowing the client to receive more positive reinforcement from the environment.