The Application of Cognitive Behaviour Therapy (CBT) For Depression: A Case Study of Iranian Female

International Journal on New Trends in Education and Their Implications
October 2014 Volume: 5 Issue: 4 Article: 08 ISSN 1309-6249
THE APPLICATION OF COGNITIVE BEHAVIOUR THERAPY (CBT) FOR DEPRESSION:

A CASE STUDY OF IRANIAN FEMALE
Leili SHAHLAEI
School of Educational Studies
University Sains Malaysia
11800, Pulau Pinang,- MALAYSIA (USM)
Shahizan HASAN
11800, Pulau Pinang- MALAYSIA (USM)
S. KIUMARSI
Graduate School of Business (GSB)
ABSTRACT
The study aims to examine the application of Cognitive Behaviour Therapy (CBT) for Depression among Iranian
students. Depression is a factor leading to behavioural disorders that can happen to a person in an undesirable
incident. To reduce the effect of depression, this study adopted a Cognitive Behaviour Therapy approach to a
case of 32 year-old woman from Iran uses stress management and relaxation techniques. A clinical assessment
showed that the woman had the highest level of depression among other depressed students. Counselling
sessions, observations, and interviews provided qualitative data while Clinical Assessment of Depression
Inventory yielded quantitative data relevant to the case. The analysis of the data revealed that the techniques
of Cognitive Behaviour Therapy were effective in reducing the level of depression experienced by the client.
Key Words: Depression, Cognitive Behaviour Therapy (CBT), Stress.
INTRODUCTION
Clinical depression affects mind, mood, body, and behaviour of an individual. A study in the United States
showed that more than 17 million people- one out of ten adults- experienced depression each year, while
almost two thirds of them apparently hardly receive help that they need. According to fall (2007) American
College Health Association-National College Health Assessment, a national study, more than 3,200 university
students were reported to be diagnosed as suffering from depression, with 39.2% of those students who were
diagnosed during the past 12 months, 24.2% presently are under therapy for depression, and 35.8% are taking
antidepressant medication in order to get cured. Among the students in a survey, 10.3% admitted "acutely
thinking of committing suicide" in the past 12 months and 1.9% really practiced the act of suicide through that
time. On the other hand, Abedini et al. (2007) studied the depression commonness amongst 190 nursing and
medical students in the Hormozgan Medical University in Iran. They came up with the fact that depression
commonness in nursing students was 60 percent, while in medical students was 49.5 percent. In a different
study, which was done by Khoshkonesh et al. (2008) the relation between hopefulness, happiness and mental
health amongst students was investigated. They discovered that there is a significant and negative relationship
between feeling happy and mental problems, physical disorders, anxiety and depression of both male and
female students. Prior to that study, Dadkhah et al. (2006) maintained that there was no significant difference
between male and female students when considering mental disorders. Accordingly, Hossaini and Mousavi
(2004) declared that 44.3 percent of the high school students in Iran experience depression. However, the aim
85
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of this study is to investigate the level of depression among group members during the group counselling and
to identify the use of management skill technique on clients stress in cognitive behaviour therapy (CBT) that
can affect the level of depression during the individual therapy.
LITERATURE REVIEW
Depression is a main issue that needs to receive a great deal of attention in order to create grounds to be
prevented or cured. Students are the ones that make contributions to the development of society; therefore, it
is of a great importance to have students who will later be healthy in their occupations. For example, Jafari
(2011) examined the amount of happiness and its contributing factors amongst students in Isfahan University
of Medical Sciences. He then, declared that 78 percent of students were benefiting from the high amount of
happiness, and he claimed that the rests had a medium amount of happiness. It is interesting to note that in
this study, cognitive and behavioural factors as well as self-disclosure were considered as the most effective
factors in determining the students' level of happiness. In fact, according to Fall (2007) American College Health
Association-National College Health Assessment, a national study of roughly 20,500 college students in 39
campuses showed that 43.2% of the students were reported as "emotion so depressed, it was hard to
function" at least one time in their last 12 months. While being in Antarctica Ahmady et al. (2007), investigated
organizational role stress amongst faculty members of medical schools in Iran and discovered that role stress
being experienced relatively in higher degree by the faculty members. This assertion was in conformity with
Sarason (1984) who said that test anxiety reduces the performance of those who experience it. To date, the
CBT treatment of depression among students has been conducted by a number of researchers in different
countries (Weiner, 1970). However, in the case of Iran, these types of treatment (CBT) have received very little
attention and in-adequate care from the parts of the health personnel, hospital management and Iranian
government. This resulted in the in-efficiency and ineffectiveness of the treatment. Exploring this issue is
therefore very crucial in the life of depressed students of Iran.
In fact, Rhonda Woodcock (2006) stated that CBT has become an accepted and empirically validated
therapeutic approach in psychotherapy for a number of different presenting concerns. Moreover, Yousefy et
al. (2010)s findings showed that CBT helps reduce hidden and manifest anxiety and improve the quality of life,
as well as emotional, physical, and social function in patients with a cardiovascular disease. They also suggested
that the methods of anxiety reduction and improvements of quality of life should be taught to coronary artery
disease patients via cognitive behavioural therapy programs. Rafiee, Sohrabi, Shams, and Forough (2012) have
claimed that a chronic pain is one of the most prevalent reasons of referral to health centres. CBT has therefore
been considered an effective treatment for a chronic pain, to evaluate the efficacy of CBT in patients with a
chronic musculoskeletal pain. These researchers also reported that psychological as well as medical treatment
can be helpful to the patients with a chronic pain. In fact, Arani And Kakia (2013) defined depression as one of
the most common psychological disorders. In recent years, cognitive-behavioural group therapy has also
received much attention for depression treatment. Hamid et al. (2013) also proposed that CBT become an
effective method employed to enhance coping strategies and symptoms among patients addicted to drugs.
Pour (2014) then concluded that CBT can be used as an effective intervention method in women with high
depression treatment.
RESEARCH METHODOLOGY
Both quantitative and qualitative methods were used to collect data in this study. Pre-test and post-test
questionnaires were used for the purposive sampling for a prospective client. A sample selection was applied
on depressive patients who showed signs of depression from the results of the pre-test instruments, the CAD
depression inventory. This qualitative research was using a single client. Therefore, a transcription of what has
been discussed by the patient and the researcher, during the 10 sessions of counselling, was prepared to select
the cases and determine data gathering and analysis techniques. The CAD is a 50-item self-report list which is
to a high extent comprehensive, reliable, and sensitive to depressive symptomatology throughout the lifetime.
It is approximately in the middle of signs of depression in children, adolescents, and adultsdepressed mood
86

and anhedoniaas well as the further seven criteria for major depressive episodes which are listed in the DSMIV-TR.
Table 1: Study Design
Number
1 (Female)
Note: O1= pre-test
Pre-Test
O1
x= Treatment
O2= post-test
Treatment
X
Post-Test
O2
FINDINGS
With regards to the research questions of the present study, the collected data were processed and analysed
using both quantitative and qualitative analyses. In quantitative methodology the researcher applied pre-test
and post-test. And in the qualitative study interview and observation were used. The first research question
was answered based on the quantitative analysis on the clinical assessment of depression (CAD), whereas the
second research question was answered through the qualitative analysis of the process and techniques of
cognitive behavioural therapy (CBT). Furthermore the qualitative analysis of the counselling transcripts was
used to answer the second research question.
1. Question :Is there any depression among group members during the group counselling?
Table 2: Level of Depression among Group Members
No Gender
Name
Raw Score
T Score
1
F
.........
119
69.25
2
F
.........
110
62
3
F
Sara
139
77
4
F
........
135
75
5
M
.......
93
54
6
M
..........
108
61.5
%II
91.5
90
99
99
65
85.25
%90CI
60-69
60-69
72-78
72-78
60-69
60-69
Qualitative Classification
Mild clinical risk (MCR)
Significant clinical risk (SCR)
Significant clinical risk (SCR)
Table 2: It shows that according to the clinical assessment of depression (CAD) the highest level of depression
amongst members is demonstrated in student with the T score of 77%. And the lowest level of depression
amongst the members is found in one of the males with the T score of 54%.
The counsellor formed a counselling group including 6 members to evaluate the members of the group and to
identify the level of depression amongst them. In order to carry on the study, the counsellor used clinical
assessment of depression (CAD) inventory. Applying clinical assessment of depression (CAD) test, the result
showed that 4 members of the group were at the level of mild clinical risk of depression (MCR) and 2 members
of the group were at the level of significant clinical risk (SCR) of depression, but Sara with the T score of 77
suggested the highest level of depression amongst the members.
Question 2: Does the stress management technique successfully help the clients stress during the
counselling sessions in cognitive behaviour therapy?
During the third session, it was found out that Sara worried a lot about herself and this is one of the causes of
her depression. She talked about her experience of losing properties at airport when she first came; she lost
her suitcase which consisted of her important belongings and properties, such as her money, her documents
and other things. The client saddened about the loss of her job and her friends and it was expressed by her for
many times during the counselling sessions. Another cause of her depression was the sadness she carried on. In
addition to feeling so sad, she complained about her night dreams. She expressed that in her dreams, she was
upset and alone amongst lots of people. She also mentioned that she had many nightmares and she is not
relaxed during her sleeping times. She said I always think a lot before sleeping. The client expressed that she
worried about herself. To conclude, it can be noticed that her depression is caused by her sadness and the fact
that she was a sad person led her to this situation. She mentioned that she lost her job and her friends and so
many other possible things. As a result, it can be said that she worries about her future and some experiences
87

of these kinds. She, in fact, was feeling sad about herself because of many lacks; she lacked her job, friends and
her boyfriend.
The first technique of cognitive behavioural therapy was applied by the counsellor to help the client to reduce
her depression level. Stress management technique was amongst the techniques used by the counsellor. The
counsellor showed some slide to the client to let her know that how stress can disturb her body and her
emotions. The counsellor gave explanations about her homework related to the applied technique. In
conclusion, it has been clarified that one of the causes of depression of the client was her worries about her
future. Therefore, the given technique can help the client in the process of reducing her depression. During the
fifth session, the client talked about her emotions. She expressed that she could not show her emotions to her
friends. She, then, explained she missed many of possible, good situations just because she was not able to
demonstrate her feelings. She lost her boyfriend and many of her other friends and she complained about her
relationships with others. The client also expressed that she could not establish a balance within her
relationships with her friends. She said that she was so serious because of some disciplines that she considers
for herself. She mentioned that she did not like any relationships with others as she talked about such things
for a long time.
The Effectiveness of Counselling Techniques of CBT
How effective is the counselling techniques of cognitive behavioural therapy in reducing depression in the
patient with depression?
Table 3: Results of Pre-Test taken by Sara
Scale
Raw
score
Depressed Mood (DM)
65
T
score
81
%II
90% CI
Qualitative classification
99
80
Anxiety /Worry(AW)
Diminished Interest(DI)
31
19
70
80
97
99
70-79
80
Cognitive and Physical

Fatigue(CPF)
Cad Total Scale (CAD)TS)
24
62
90
60-69
Very Significant Clinical Risk

(VSCR)
Significant Clinical Risk (SCR)
Very Significant Clinical Risk
(VSCR)
Mild Clinical Risk (MCR)
139
77
99
70-79
Table 3: The level of depression of Sara according to the clinical assessment of depression (CAD), as it can be
observed, the highest T score is the depressed mood (DM) with 81 and the lowest T score is devoted to the
cognitive physical fatigue (CPF) with 62.
Table 4: The detailed Results of Post- Test taken by Sara
Scale
Raw Score T Score
Depressed Mood(DM)
Anxiety /Worry(AW)
Diminished Interest(DI)
Cognitive and Physical Fatigue(CPF)
Cad Total Scale (CAD)
30
18
12
18
78
45
44
56
49
47
%II
90%CI
Qualitative Classification
39
27
73
45
41
<59
<59
53-56
59
59
Normal Range(NR)
Normal Range(NR)
Normal Range(NR)
Normal Range(NR)
Normal Range(NR)
Table 4: The level of depression of Sara according to the clinical assessment of depression (CAD) derived from
the post test. Based on what is evident in table 3, and according to the scores of depressed mood (DM),
anxiety/worry, diminished interest and cognitive physical fatigue (CPF), the level of depression is reduced to a
favourable range normal range.
88

Table 5: Result of Pre-Test & Post Test

Total Scale (CAD)
Raw score
T-Score
Pre-test
139
77
Post-test
78
47
%II
99
41
90% CI
70-79
59
Qualitative classification
Normal Range(NR)
Table 5: demonstrates a significant difference between total score of the clinical assessment of depression
(CAD) in pre-test and post- test. The scores are definitely calculated through clinical assessment of depression
(CAD).
Finally, during the tenth session of counselling period, the counsellor applied the post -test for evaluating the
level of depression of the client. The clinical assessment of depression (CAD) was used to determine the results
which were previously given in table 3. It was evident that after ten sessions of counselling, the client showed
that her emotions were all back to normal status. She explained that she had regained her interests to establish
and keep relationships with her friends. The client expressed that she started to add vegetables and fruit into
and remove sugar from her diet. One more interesting change in the activities of the client was she started to
exercise and she made new friends. Furthermore, she said that she did not have nightmares anymore and this
caused her to be relaxed while sleeping. At last but not least, she declared that she could stop her negative
thinking which was a considerable positive change to help her to feel happy. It can be said that the three
techniques of cognitive therapy; stress management technique, and relaxation technique affected the level of
depression in this case study according to the given scores of the post -test in the session10 (Table 5).
DISCUSSION
Level of depression among group members during the group counselling the findings of this study show that
there is the highest level of depression among group members during the group counselling where the
difference was demonstrated in students with the T score of 77% as highest and the level of depression of the
other students within the group was a T score of 54% as low. Additionally, Abedini et al. (2007) studied the
depression commonness amongst 190 nursing and medical students of the Hormozgan Medical University.
They came up with the fact that depression commonness in nursing students was 60 percent while in medical
students was 49.5 percent. Another study in which Becks depression questionnaire was applied, it was
mentioned that 34% of the respondents suffered from depression amongst 4020 high school students in Rasht,
north of Iran (Modabber-Niaet al., 2006).
Qestion3: How does stress management technique successfully help the clients stress during the counselling
sessions in cognitive behaviour therapy?
Level of Depression before and after the Sessions
The clients level of depression was measured by the pre-test and post- tests for the clinical assessment of
depression (CAD). The collected data showed that there was a reduction in the scores from the significant
clinical risk of depression to a normal range. The detailed reductions in the scores are; the level of depressed
mood (DM) from 81% to 45%, the level of anxiety/worry (AW) from 70% to 44%, the level of diminished
interest (DI) from 80% to 56% and the level of cognitive and physical fatigue (CPF) from 62% to 49%. Overall,
the total score of depression according to the clinical assessment of depression (CAD) suggests a reduction
from 77% to 47%. It can be observed that the total level of depression after and before the counselling sessions
is significantly different. In other words, the level of depression which had been experienced by the client of
the present study did levelled down from the status of significant clinical risk (SCR) of depression to the normal
range after the counselling sessions were successfully completed.
The Causes of Depression of the Client
The findings of this study demonstrated that many reasons could cause the client to be affected by depression.
During the background sessions 2, 3, 4, 5, the client was given the opportunity to express herself in terms of
thoughts, her emotions and her behaviours. In session 3, the cause of depression was detected to be the fact
that she was worried about loss of her job, loss of her friends and loss of her boyfriend and a more recent loss
89

of her important belongings and properties such as; losing of a lot of money, her important documents and so
many other things. She has also explained that she was sad and lonely. Later on, in session 4 she expressed that
she worried about her negative thinking and that was a big problem for her. She described she was used to
thinking a lot, she was used to thinking about something bad which might happen for her. In addition, she did
not trust her abilities and capabilities in her life. The conversations between the counsellor and the patient
during session 5 revealed that she worried about her relationships with her friends as she described she could
not establish a balance between her emotions and her behaviours which might be the reason why she could
not keep the relationships with her friends. All in all, she deeply felt sad about her relationships and her
negative thinking.
The Effects of the Process and CBT Techniques
The techniques of the cognitive behavioural therapy were used in a flexible way in the process of helping the
client to reduce the experienced depression. The counsellor had utilised the basic cognitive behavioural
techniques to help the client to develop an insight to the causes of her depression. At first, the counsellor only
applied fundamental counselling skills, such as active listening, minimal encouragement and paraphrasing.
Active listening is the responsibility of the counsellor to take the content of the clients responses into account
as well as taking notes of the implied meaning. The counsellor is supposed to pay attention to the
accompanying gestures, emotions, hesitations and silences during the sessions of therapy. Consequently,
applying the fundamental counselling skills aimed to build a reliable therapeutic relationship between the
counsellor and the client so that the client felt valued and that she could express her feelings or whatever
problem she was in the counselling session for. These fundamental skills prepared the grounds for the patient
to feel secure and relaxed while talking about her problems. When the needed trust was established, the
counsellor started to play more effective roles, letting the client recognize her unhelpful thoughts which had
disturbed her life. A problem list was prepared in this step for the reason of creating the agenda to be used for
future counselling sessions. The counsellor cooperated with the client to try to replace these dysfunctional and
unhelpful thoughts with appropriate and logical ones, by demonstrating to the client how these thoughts had
affected her life, and by teaching the client how to think again and differently.
The effectiveness of Cognitive Behaviour Therapy (CBT) in Reducing Depression of the Depressed Client
In general, this research had sufficiently verified that the CBT approach had helped to decrease depression
level of the client of the present study. For the purpose of this study, the counsellor applied three techniques of
cognitive behaviour therapy CBT; stress management and relaxation techniques. The techniques helped the
counsellor to gain satisfactory outcomes. The client had also mentioned that she was satisfied with the
counselling sessions. It should be mentioned that the client was given the time to talk about her thoughts and
her behaviours. She participated all the sessions and was willing to do her homework and given practices
between sessions. To sum up, the researcher discovered that the CBT approach was successful but the
counsellor needed to develop her skills for the purpose of cognitive behaviour therapy.
Thought
Activity
Mood
Relationship
Figure 1: Basic Module of CBT
90

Figure 1 Connection between thoughts, feelings, physical symptoms and behaviour, Therefore by making a
positive change in one of these areas, a positive change will be obtained in the total behaviour which will lead
to well being.
CONCLUSIONS
In the current study, the pre-test of the clinical assessment of depression (CAD) was conducted to determine
the level of depression of a group. It aims to select the subject of the study. A female client with the T score of
77 was recognized to be at the significant clinical risk of depression. The treatment for the clients over a 10session period was then carried out to gain deep insights into the causes of depletion. One technique of CBT
was therefore suggested. That is stress management applied to reduce the depression level of clients. The
findings of this study demonstrated that CBT is an effective as the post test of CAD taken by the clients
suggested a T score of 47 which is considered to be in a normal range. Therefore, it showed that CBT is an
effective approach to reduce the depression level of the clients.
BIODATA AND CONTACT ADDRESSES OF THE AUTHORS

Ph.D Candidate, School of Educational Studies, Universiti Sains Malaysia, 11800, Pulau
Pinang, Malaysia (USM), her research interests include counseling psychology, Clinical
Psychology, Counseling Group (CBT, IPT)
Leili SHAHLAEI
University Sains Malaysia, 11800, Pulau Pinang- MALAYSIA (USM)
E. Mail: [email protected]
(B.E.d. UPM, MA Western Michigan, USA, Phd Leeds UK) Senior lecturer. Certified
polygraph Examiner (Malaysia/USA). Member of the British polygraph Association.
Member of British &European polygraph Association. Association of psychological and
Educational Counsellors of Asia pacific (APECA)/life Member. Principal Consultant-Training
& Development USAINS Holding sdn, Bhd USM. School of Educational studies. 11800
universiti Sains Malasia (USM).
Shahizan HASAN
School of Educational Studies, University Sains Malaysia
S. KIUMARSI is a PhD candidate at the Graduate School of Business (GSB), Universiti Sains
Malaysia, USM, Penang. His research interests include innovation business IT, service
innovation and marketing.
S. KIUMARSI
Graduate School of Business (GSB), University Sains Malaysia
91

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International Journal on New Trends in Education and Their Implications

October 2014 Volume: 5 Issue: 4 Article: 08 ISSN 1309-6249