CBT for difficult-to-treat depression: self-regulation model

Behav Cogn Psychother. 2023 Nov;51(6):543-558. doi: 10.1017/S1352465822000273. Epub 2023 May 12.


Background: Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients do not complete therapy, do not respond to it, or subsequently relapse. Non-responders, and those at risk of relapse, are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk. This is a heterogeneous group of clients who are currently difficult to treat.

Aim: The aim was to develop a CBT model of depression that will be effective for difficult-to-treat clients who have not responded to standard CBT.

Method: The method was to unify theory, evidence and clinical strategies within the field of CBT to develop an integrated CBT model. Single case methods were used to develop the treatment components.

Results: A self-regulation model of depression has been developed. It proposes that depression is maintained by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life goals. Depression is more difficult to treat when these processes become interlocked. Treatment based on the model builds self-regulation skills and restructures self-identity, rather than target negative beliefs. A bespoke therapy plan is formed out of ten treatment components, based on an individual case formulation.

Conclusions: A self-regulation model of depression is proposed that integrates theory, evidence and practice within the field of CBT. It has been developed with difficult-to-treat cases as its primary purpose. A case example is described in a concurrent article (Barton et al., 2022) and further empirical tests are on-going.

Keywords: cognitive behavioural therapy; complex cases; depression; self-regulation.

MeSH terms

  • Cognitive Behavioral Therapy* / methods
  • Comorbidity
  • Depression / therapy
  • Humans
  • Recurrence
  • Self-Control*
  • Treatment Outcome