On Getting (And Then Staying) Well
A Deep Dive into CBT for Depression and Relapse Prevention
"I see all these techniques as kind of loosening the hold that the thought has over people.”
104811 CBT Foundation Series
The CBT Foundations Series is a three-part training designed to strengthen clinicians’ understanding and application of Cognitive Behavioral Therapy from the ground up. Rather than focusing solely on techniques, this series emphasizes the theoretical model, core competencies, and clinical decision-making processes that support effective CBT practice across settings and populations. The series explores the essential therapist competencies—such as collaboration, session structure,...
"I often say that depression was kind of my first love, which sounds a bit strange, but in professional terms, it definitely was. It's where I got started, and I've maintained an interest in it ever since."
John Ludgate, PhD, has been a psychotherapist for more than 30 years, is a Founding Fellow of the Academy of Cognitive Therapy, and wrote the relapse prevention chapter in the American Psychological Association's Handbook of CBT (2021). In a recent three-hour Impact CE presentation in October, he laid out standard Beck-style CBT for depression, the newer approaches that have joined it over the past 10 to 15 years, and the problems that most often stall treatment: suicidality, chronic depression, and relapse.
An Experiment Behind the Method
Aaron Beck began as a psychoanalyst who wanted to research depression, a pursuit Ludgate said "was kind of frowned upon by analysts back then."
In early studies at the University of Pennsylvania, depressed and non-depressed participants completed a problem-solving task and were then told they had done better, or worse, than they actually had. Depressed participants underestimated their own performance. Negative feedback impaired their next attempt, and positive feedback improved it. Non-depressed participants showed the reverse: criticism made them try harder, and praise made them complacent.
Beck's conclusion, in Ludgate's telling, was that "even perceived failure by a depressed person will mean that they'll kind of give up quite quickly." Therapy should, therefore, engineer success by breaking tasks into steps small enough that the client is likely to complete them. That idea became graded assignments, and it still underpins much of the behavioral work in CBT for depression.
Testing Thoughts Without Arguing With Them
Beck's model sorts depressive thinking into negative thoughts about the self, the world, and the future -- the negative cognitive triad.
But, not every client shows all three. As Ludgate put it, "a triangle can be a different shape." Thoughts about the future deserve particular attention because they track hopelessness, a strong predictor of suicide.
In an evidence review, a therapist first asks how strongly the client believes the thought, from 0 to 100, because a thought held at 20% does little damage, and one held at 90% does a lot. The therapist also asks what the client means by using a word like "failed," since the criteria are often black and white. Evidence for the thought is often addressed first, as Ludgate has "seen therapists go quickly to the evidence that goes against it, but I wouldn't do that." Ludgate went on to explain that going into the evidence for the client's thought often minimizes the client's thinking and shows the therapist doesn't believe it. Only after the client has listed everything should the therapist ask what doesn't fit, lowering the bar if necessary: anything partly successful, anything a friend would say. According to Ludgate, the client should supply the answers, not the therapist.
A belief that drops from 80% to 50% counts as progress, and a restated thought such as "I haven't been able to maintain a job for as long as I would like to have" is far less damaging than "I failed at everything." Ludgate describes the effect as "loosening the hold that the thought has over people," adding that "encouraging skepticism is to me a good part of CBT."
The same spirit applies to matters like distortions: Ludgate advises to normalize thoughts like these at first: he tells clients he once locked his keys in his car and thought, "things like this are always happening to me." After noticing a distortion could be happening, clients are then advised to practice running through a thought record. In practice this helps the client manage their emotions as their minds take them through the columns of situation, feelings, automatic thoughts, and distortions.
103471 CBT for Depression: New Advances and Standard CBT Approaches
Major Depression and other mood disorders are frequently encountered in clinical practice and counselors and therapists often find these clients challenging for a number of reasons. Cognitive Behavioral Therapy (CBT), as an approach to treating depression, which was first described and researched in the late 1970s and early 1980s continues to be the gold standard for effective treatment of depression...
Asking Whether a Thought Is Useful
One technique Ludgate was surprised more therapists don't use is the cost-benefit analysis within a clients thinking, the setting aside of whether a thought is accurate and asks only whether it helps.
"Negative thinking comes on when you're depressed. You didn't decide to be negative." He then walks clients through a lunch with a friend, in which anticipating that it will be a disaster tends to make it one. One client's reaction: "Isn't that like a self-fulfilling prophecy?" As Ludgate put it, "Dysfunctional thinking doesn't help us. Whether it's true or false is kind of irrelevant."
Rumination-focused CBT, developed by Edward Watkins, extends the logic. Ludgate offers a working definition: going around the same loop three or more times. The steps are to notice it, weigh its costs and benefits, and substitute problem solving. "Ruminating doesn't ever solve a problem because you're only in your head, and there's absolutely nothing you can do if it remains in your head." Wrapping up the topic, Ludgate shared an interesting example: One client spent an hour every day, for 20 years, on a woman who had never repaid a loan. Once this time-cost was pointed out to her, she finally saw the cost. She took up a hobby instead.
Action Before Motivation
Behavioral activation starts with a baseline: an hourly record of activity and mood, on a 0 to 100 scale, across a week.
Clients often discover that their mood isn't flat.
It might range from 10 to 30, and the lows tend to cluster in particular situations, such as lying awake in bed. From there, the client sets one or two SMART goals per day, each broken into very small steps.
Clients also rate their sense of accomplishment from 0 to 5. Mood can lag for days or weeks, Ludgate said, "but the sense of accomplishment may keep you going in the meantime." Black-and-white thinkers may dismiss partial progress, so Ludgate reframes it: "You had done 0% of this particular thing, and now you've done 20%... is 20 better than zero?"
Pleasure scheduling works the same way. Clients who can't answer "what did you used to enjoy?" often respond to a checklist ("oh yeah, that one and that one"). Ludgate has them predict their enjoyment beforehand and rate it afterward, because they "will often underestimate how pleasurable something is." Some clients feel guilty or unworthy of pleasure, which calls for cognitive work on those beliefs.
Problem solving rounds out the toolkit, using a five-step method (Select the Problem > Generate Options > Evaluate Each > Choose and Act > Review). Brainstorming is kept separate from evaluating, "because you will give up too easily" otherwise. Practice starts with a hypothetical, such as a car breaking down on the highway, before moving to larger problems.
103275 Deconstructing Anxiety: Cracking the Code of the 5 Core Fears
There are many psychotherapeutic approaches for anxiety disorders that have been shown to be effective (Bandelow et al., 2015), with Cognitive Behavior Therapy (CBT) generally better than other approaches (van Dis et al., 2020). The Deconstructing Anxiety model is a new synthesis of evidence-based techniques, highlighting the common themes that have been empirically demonstrated as most helpful. This model teaches...
Beyond Standard CBT
Ludgate pointed to several additions byond standard CBT.
Metacognitive work addresses what clients think about being depressed, because a belief that depression means weakness can lead to dropping out. Compassion-focused therapy targets the shame many clients feel, and Ludgate distinguishes it carefully: self-compassion "is not self-criticism," and it "also isn't self-pity." He borrows DBT's self-soothing categories (physical, cognitive, and sensory) for hard days, and notes that positive affect therapy, a newer approach built on savoring and anticipating positive experiences, has shown benefits for life satisfaction and well-being.
When clients can't recall their tools in a low moment, the fix is access, not memory. Coping cards, phone apps, and recordings help, because "all you have to remember is, where is it?"
Suicidality as a Problem to Be Solved
Ludgate's CBT conceptualization treats suicidal thinking as an attempt to solve a problem: "Anybody who's thinking of suicide is trying to solve a problem... in a very kind of final and permanent way." The therapist's task is to identify the problem.
Common ones include an intolerable situation, unbearable emotional or physical pain, overestimated life problems, underestimated coping resources, premature abandonment of solutions, and the belief that the present will also be the future. Research showing that people with attempt histories tend to show these patterns was part of what led to problem-solving training, which has been shown to reduce suicidality.
In acute crisis, the posture shifts from collaborative to active. By his count, Ludgate has hospitalized clients against their wishes twice, and he addresses the worry that this will rupture the relationship: "the client will be alive. They can find another therapist if you can't repair it." Both clients continued working with him. Crisis sessions also cover therapist availability, delaying impulses with a "not today" approach, and securing means, such as locking up medication and removing access to hazardous items like firearms.
Restoring hope is part of the session's goal. Ludgate tells clients "there are things we haven't tried yet." Tools include safety planning (adapted from Wenzel, Brown, and Beck's Cognitive Therapy for Suicidal Patients), a cost-benefit analysis of living and dying, and the Reasons for Living Inventory. A hope chest, whether a physical box or an app, collects photos, music, and letters in one place. The safety plan needs repeated review: "some therapists kind of relax once they have the safety plan and then they don't ask the client about it again, but you should."
Afterward, vulnerability reduction targets cognitive rigidity, black-and-white thinking, and the belief of being a burden, which can stop a client from using the plan's third step, reaching out.
103666 Evidence-Based Treatment of Depression
Major Depression and other mood disorders are frequently encountered in clinical practice and mental health professionals often find clients presenting with these diagnoses challenging for several reasons. Cognitive Behavioral Therapy (CBT) was first described and researched in the late 1970s and early 1980s and continues to be the gold standard for effective treatment of depression. CBT has been shown to...
When Depression Doesn't Lift
Persistent depressive disorder calls for emphasis on cognitive style rather than individual thoughts.
Ludgate describes these clients as "big time discounters," with a "yes, but" response to nearly any suggestion, and a mental filter that registers only negatives. He asks them to note one positive event or reason for gratitude each day. For skepticism, he offers an experiment: "I think it might work. You think it probably won't, but are you willing to do the experiment six times and see what happens." For motivation, he borrows an example from daily life: "Nobody ever feels motivated to go to a dentist, but they do it anyway."
This echoes themes in Ludgate's earlier Catalyst article, CBT for Challenging and Complex Problems, which described clients with long-standing patterns who may report that they have "always been this way" and whose progress "will rarely be linear." The article cautioned against labeling such clients "resistant" or "difficult," since doing so "precludes finding a solution" when therapy stalls.
For chronic depression specifically, Ludgate described the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), developed by James McCullough. It treats chronic depression as long-term interpersonal failure, with perceptual blind spots that keep clients from linking their behavior to its effects on others. In situational analysis, clients describe a recent interaction that went poorly, state the desired outcome and the actual outcome, and identify what they could have done differently. Discrimination training helps them distinguish the therapist, and other current people, from past people who hurt them. The therapist also gives feedback about the effect the client is having, such as feeling discouraged by constant "yes, but" replies, framed so that the therapist isn't stepping back. Ludgate cited response rates of 52%, rising to 85% when combined with medication.
Staying Well, Not Just Getting Well
Ludgate cited a 50% to 70% response to CBT, usually closer to 70%, with relapse rates about half those seen with medication at one- and two-year follow-up.
About 30% of CBT responders still relapse, compared with roughly 76% who stop antidepressants after short-term treatment. He added that CBT shouldn't rest on that number.
"You don't wake up one morning and you're completely depressed again," Ludgate mused. The CBT model treats relapse as a process rather than an event, and several predictors are within a therapist's reach: low self-efficacy, residual symptoms at discharge, hopelessness, dysfunctional attitudes like perfectionism, a global and internal attributional style, and low life satisfaction.
The practical implications run through the whole course of therapy: monitor scores every couple of weeks, feed them back, and ask what the client did to produce the progress. On shifting toward a consultant role by sessions 16 or 17, Ludgate tells clients, "My goal for you is to make me... unnecessary." Near the end, identify early warning signs, anticipate high-risk periods (one client struggled on weekends), and write an emergency plan. Ludgate uses a car metaphor: dashboard lights are the warning signs, and the weather and other drivers are life stressors.
In Ludgate's October session, his broader aim for clients goes beyond symptom relief. Quoting Martin Seligman, he said therapy shouldn't "just be weeding the garden. You should be growing flowers."
In his words, the goal is for clients "to stay well, not just get well." ◼
104811 CBT Foundation Series
The CBT Foundations Series is a three-part training designed to strengthen clinicians’ understanding and application of Cognitive Behavioral Therapy from the ground up. Rather than focusing solely on techniques, this series emphasizes the theoretical model, core competencies, and clinical decision-making processes that support effective CBT practice across settings and populations. The series explores the essential therapist competencies—such as collaboration, session structure,...
Want to make the most of everything Impact CE has to offer?
The Ignite Membership unlocks Premium events and Masterclasses, Unlimited Live Webinars, Hundreds of Self-Paced Courses, a Growing Library of Recorded Content, and Free E-Library access — all in one place, for one low annual price. Learn more about Ignite today.
