When Clients' Morbid Avoidance and Chronic Anger Impede Their Response to Cognitive-Behavioral Therapy for Depression

In spite of the fact that cognitive-behavioral therapy (CBT) for major depressive disorder is an empirically supported treatment, some clients do not respond optimally or readily. The literature has provided a number of hypotheses regarding the factors that may play a role in these clients' difficulties in responding to CBT, with the current paper focusing on two of these: (a) morbid avoidance, and (b) chronic anger. Clients who engage in extreme avoidance patterns (including experiential avoidance) often leave therapy prematurely, and even when they attend sessions they typically struggle to face homework assignments and other central aspects of treatment. This problem is compounded when the clients also maintain longstanding feelings of anger and bitterness secondary to beliefs about having been wronged in life. They reason that they have the right to refuse any situation or experience that would add to their subjective sense of burden, including the challenging work of CBT. The case of “Trixie” highlights how the CBT therapist has to strike a balance between nurturing and validating the client so as to encourage her to remain in the depression treatment study in which she is enrolled, and focusing on issues and promoting homework assignments that are most germane to her depression and its maintaining factors of avoidance and anger. Implications for conducting CBT and research with depressed clients such as Trixie are discussed, including methods to retain the clients in treatment, facilitating their learning of and memory for the therapy, and repairing strains in the therapeutic relationship.