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Expert View: A CBT model of depression

Shirley Reynolds, Director of The Charlie Waller Institute at The University of Reading, describes the 'Hot Cross Bun Model' at the centre of CBT.
So let’s imagine that I am taking my son or daughter to school. And I see the mums I know at the school gate, and I can see they’re talking about something. And I remember it’s somebody’s birthday. I think, oh, OK they’re thinking about the party. And I’m going to talk to them. I must go. That’s exciting, there’s a party. So something happens, and I make sense of it. I interpret what’s going on. And in this case, I think, oh, there’s a party. I think, oh, that’s great, how exciting. So there’s my thought. I’m excited, I’m looking forward to it. So that has an impact on my behaviour. I think, right, I’ll go and have a chat with them about it.
I’m going to go find out what’s going on. So I go over and I talk to them. And we find out, yes, it’s a party. And that makes me feel quite happy and excited. And because I’m happy and excited, I have a physiological reaction. My heart starts beating a bit faster. And I have that kind of sensation internally. So all of those things, then, what I expected to happen, what I thought was happening, my behaviour, how I feel, and the physical reactions, all connect with one another. OK. So imagine I’m taking my child to school. I get to the school gate. And I see a bunch of mums talking to each other. It’s not clear what they’re talking about.
And I forget that it’s somebody’s birthday. Or I remember it’s somebody’s birthday. And I think, I probably won’t get an invitation. How awful. They look so happy. And I’m– but they’re not talking to me. So that instantly makes me feel sad. Instantly has that kind of reaction of “ugh.” It always happens to me. It’s so awful. Why am I such a– why don’t they like me? And because I feel like that, I’m not going to talk to them. Because I feel that would be more embarrassing. And I’ll bring them down, too. So I don’t go and talk to them. I take my kid and I drop him off at school. And I buzz off home.
And I feel terrible about that. And because I’m feeling sad, I start feeling rather tired and a bit listless and don’t have much energy. So the day starts on a downward spiral. So the exact same circumstance, depending on what I imagine is going on, these two completely different sets of events. So if we have a hot cross bun, and we understand how certain things have happened in the order they have happened, what we can do in therapy is look for ways to try something different. Rarely do emotions just come out of nowhere. Usually there’s a path that you can see, a chain that you can follow. Something happens. You make sense of it in one way or another.
You might behave in a certain way because of that. And you feel a certain thing. So what it shows you is that there’s ways to actually interrupt that. So let’s imagine I’m that mum at the school gate. And I have that sense of awful being left out, and not being invited to the party, and feeling miserable and awful. What could happen is that the next day, I go back and I’m still embarrassed. And I don’t want to talk to those mums, so I stay away from them. And that makes things worse. Because then, more and more, I avoid them. And I’m isolated. So actually what I feared becomes true.
What you would do in therapy using the hot cross bun is to identify actually what would have been a different reaction. And what might have happened if you had done a different thing. So you encourage the client or the patient to test this out. So I have a belief that they’re not going to invite me. They don’t like me. And it’s awful. Actually what we might need to do is really do a little experiment to see if that’s actually true. So instead of walking away and keeping ourself to ourselves, maybe the experiment would be, well, how about if you walk over and join in the conversation. Let’s see what would happen.
So we don’t know what we will find out in a behavioural experiment. But we will do something very different. And we will get more information about the situation. And what we won’t be doing is avoiding the situation and taking ourselves away. Because it’s often the avoidance of the situation that really makes things much worse.

Watch Shirley explain how someone without depression might interpret an ambiguous situation (thoughts), and the types of feelings (emotional and physical) and behaviours which may occur. Shirley compares this with how someone with depressive symptoms might interpret the same information.

When you are watching the clip, for each example, try and identify the thoughts, emotions, physical feelings/symptoms and behaviour and include these in the blank hot cross bun.

The individual without depressive symptoms interpreted the situation (other mums talking at the school gate) in a positive way (they are talking about the party – great!). This makes her feel happy and excited (with associated physical symptoms) and prompts her to go up to the group to talk about this. On the other hand, the depressed individual interpreted the same situation in a negative manner (they are obviously talking about the party – I won’t get an invite, how awful). This results in a vicious cycle, whereby the person experiences immediate feelings of sadness and lethargy, and consequently avoids talking to the people in question (so she is never able to actually confirm, whether what she believes is true), which only serves to maintain her low mood.

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Understanding Anxiety, Depression and CBT

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