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Cognitive · 2005

Preventive Cognitive Therapy (PCT)

Relapse in depression is not prevented by eliminating symptoms, but by changing the relationship with the cognitive patterns that reactivate them.

Preventive Cognitive Therapy (PCT), developed by Claudi L. H. Bockting, is a specific cognitive approach designed to prevent relapse in recurrent major depression once the acute episode has remitted. Unlike classical cognitive therapy, which focuses on reducing current symptoms, PCT aims to identify and modify the cognitive vulnerability factors that remain active after recovery, especially latent negative processing styles, cognitive reactivity to mood and the persistence of underlying dysfunctional beliefs. The model assumes that, even in the absence of symptoms, certain cognitive patterns can be reactivated by mild emotional changes, triggering new episodes. The intervention therefore focuses on training metacognitive skills, questioning residual beliefs, increasing awareness of early warning signs of relapse and developing more flexible coping strategies. PCT has shown efficacy in significantly reducing relapse in patients with multiple depressive episodes, especially when applied after remission and as an adjunct to previous pharmacological or psychotherapeutic treatments. Bockting's original formulation was developed as a brief preventive cognitive therapy delivered in groups and worked mainly on cognitive content: identifying negative thoughts and dysfunctional attitudes, Socratic questioning, constructing alternative attitudes and practising these attitudes outside the session. The protocol added components not characteristic of acute cognitive therapy, such as a positive experiences diary to strengthen the retrieval of specific positive autobiographical memories, the use of positive fantasy with imagery to challenge rigid attitudes, and the creation of a personalised relapse prevention strategy. The metacognitive dimension in PCT refers above all to recognising early on the activation of cognitive patterns and responding with a preventive plan; the canonical intervention is defined not by mindfulness or defusion but by a preventive, experiential cognitive restructuring applied in the phase of remission. (Bockting et al., 2005; de Jonge et al., 2015; Bockting, 2025).

Theory of change

Relapse becomes less likely when the person detects the reactivation of depressogenic attitudes, recovers flexible alternatives and applies a preventive plan before dysphoria turns into an episode.

Core ideas

  1. Depressive relapse can begin with a subtle cognitive activation

    PCT proposes that a recurrent episode can begin when mild dysphoria reactivates depressogenic attitudes and schemas that had remained latent during remission. The sequence does not require an extraordinary external event: it can be organised out of the interaction between mood, cognitive rules, memory, behaviour and accumulated vulnerability. The intervention is therefore placed before the crisis, at the first movements of reactivation. (Segal et al., 1999; Bockting et al., 2005).

  2. Vulnerability persists after clinical remission

    The disappearance of depressive symptoms does not imply the disappearance of the factors that generate them. The underlying dysfunctional attitudes and cognitive schemas remain active as residual vulnerability, which explains the high relapse rates even in apparently recovered patients. PCT turns this period of remission into a clinical opportunity for detecting and modifying vulnerabilities before they regain strength. (Bockting et al., 2005, 2006).

  3. Dysfunctional attitudes are a central preventive target

    Unlike cognitive therapy directed at an acute episode, PCT places particular emphasis on attitudes, assumptions and personal rules that are more stable than one-off automatic thoughts. These structures can organise conclusions about personal worth, perfectionism, approval, error, loss or the future and facilitate depressive reactivity when mood changes. (Bockting et al., 2005; Beck, 1987).

  4. Recurrence increases the need for personalised prevention

    The number of previous episodes is a relevant indicator of risk, but PCT avoids turning it into a universal verdict. The history of recurrences is used to examine which signs, residual symptoms, attitudes and coping patterns have acquired the greatest weight in each person, and to build a prevention proportionate to their particular vulnerability. (Bockting et al., 2005, 2006, 2009; Legemaat et al., 2023).

  5. Therapeutic change weakens the association between dysphoria and depressive cognition

    The aim is not to eliminate all negative emotion or to forbid critical thoughts, but to reduce the force with which mild dysphoria activates depressogenic attitudes, negative memory and withdrawal behaviours. The sooner that association is recognised and an alternative applied, the lower the likelihood that the system will organise itself again around the depressive pattern. (Segal et al., 1999; Bockting et al., 2005).

  6. Specific positive autobiographical memory works as a preventive resource

    The tendency to retrieve overgeneral memories is associated with poorer problem-solving and greater depressive vulnerability. PCT introduces training in specific positive autobiographical memory as a way of increasing access to concrete experiences of support, competence, pleasure and connection that can be used in coping with low moods and challenging global negative conclusions. (Bockting et al., 2005).

  7. Positive fantasy widens alternative affect and cognition

    Positive imagery is used not as empty optimism, but as a way of evoking positive affect and making accessible possibilities incompatible with rigid depressogenic schemas. By imagining a desirable situation or a more flexible response, the person can rehearse alternative cognitions with an experiential component that strengthens their future availability. (de Jonge et al., 2015; Besten et al., 2024).

  8. Prevention requires anticipatory action and not only insight

    Understanding dysfunctional attitudes is insufficient if the person does not know how to recognise when they are activated or what to do at that moment. PCT turns the formulation into an action plan with early warning signs, cognitive responses, memory exercises, activities, support and criteria for stepping up care. The learning becomes preventive when it can be carried out outside the session and before the relapse consolidates. (Bockting et al., 2005; Bockting, 2025).

  9. Cognitive therapy can be applied after acute recovery

    PCT shows that cognitive therapy is useful not only for reducing symptoms during an episode, but also as a sequential prophylactic intervention after remission. Its aim changes: it moves from treating the crisis to modifying residual vulnerability, preparing responses to early warning signs and maintaining a more stable trajectory of recovery. (Bockting et al., 2005; de Jonge et al., 2019).

  10. The original treatment combines structure and personalisation

    The module was organised into eight weekly sessions with a fixed sequence and structure, but each participant works with their own attitudes, memories, warning signs and prevention strategies. The structure guarantees fidelity to the central mechanisms; the personalisation allows the plan to respond to the particular way in which each history of recurrent depression organises itself again. (Bockting et al., 2005).

Influences

  • Beck's cognitive therapy
  • The cognitive vulnerability model of depression
  • Teasdale's differential activation model
  • Schema theory
  • Research on cognitive reactivity to mood
  • Research on overgeneral autobiographical memory
  • Cognitive-behavioural relapse prevention

Key references

  • Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy: An International Quarterly, 1(1), 5–37.
  • Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. Guilford Press.
  • Segal, Z. V., Gemar, M., & Williams, S. (1999). Differential cognitive response to a mood challenge following successful cognitive therapy or pharmacotherapy for unipolar depression. Journal of Abnormal Psychology, 108(1), 3–10. https://doi.org/10.1037/0021-843X.108.1.3
  • Bockting, C. L. H., Schene, A. H., Spinhoven, P., Koeter, M. W. J., Wouters, L. F., Huyser, J., & Kamphuis, J. H. (2005). Preventing relapse/recurrence in recurrent depression with cognitive therapy: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 73(4), 647–657. https://doi.org/10.1037/0022-006X.73.4.647
  • Bockting, C. L. H., Spinhoven, P., Koeter, M. W. J., Wouters, L. F., Visser, I., & Schene, A. H. (2006). Differential predictors of response to preventive cognitive therapy in recurrent depression: A 2-year prospective study. Psychotherapy and Psychosomatics, 75(4), 229–236. https://doi.org/10.1159/000092893
  • Bockting, C. L. H., Spinhoven, P., Wouters, L. F., Koeter, M. W. J., & Schene, A. H. (2006). Prediction of recurrence in recurrent depression and the influence of consecutive episodes on vulnerability for depression: A 2-year prospective study. Journal of Clinical Psychiatry, 67(5), 747–755. https://doi.org/10.4088/JCP.v67n0508
  • Bockting, C. L. H., Spinhoven, P., Wouters, L. F., Koeter, M. W. J., & Schene, A. H. (2009). Long-term effects of preventive cognitive therapy in recurrent depression: A 5.5-year follow-up study. Journal of Clinical Psychiatry, 70(12), 1621–1628. https://doi.org/10.4088/JCP.08m04784
  • de Jonge, M., Bockting, C. L. H., Kikkert, M. J., Bosmans, J. E., & Dekker, J. J. M. (2015). Preventive cognitive therapy versus treatment as usual in preventing recurrence of depression: Protocol of a multi-centered randomized controlled trial. BMC Psychiatry, 15, 139. https://doi.org/10.1186/s12888-015-0508-8
  • Bockting, C. L. H., Smid, N. H., Koeter, M. W. J., Spinhoven, P., Beck, A. T., & Schene, A. H. (2015). Enduring effects of preventive cognitive therapy in adults remitted from recurrent depression: A 10-year follow-up of a randomized controlled trial. Journal of Affective Disorders, 185, 188–194. https://doi.org/10.1016/j.jad.2015.06.048
  • de Jonge, M., Bockting, C. L. H., Kikkert, M. J., van Dijk, M. K., van Schaik, D. J. F., Peen, J., Hollon, S. D., & Dekker, J. J. M. (2019). Preventive cognitive therapy versus care as usual in cognitive behavioral therapy responders: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 87(6), 521–529. https://doi.org/10.1037/ccp0000395
  • Legemaat, A. M., Burger, H., Geurtsen, G. J., Brouwer, M., Spinhoven, P., Denys, D., & Bockting, C. L. H. (2023). Effects up to 20-year follow-up of preventive cognitive therapy in adults remitted from recurrent depression: The DELTA study. Psychotherapy and Psychosomatics, 92(1), 55–64. https://doi.org/10.1159/000527906
  • Besten, M. E., van Tol, M.-J., van Kleef, R. S., & Bockting, C. L. H. (2024). Understanding mechanisms of depression prevention: Study protocol of a randomized cross-over trial to investigate mechanisms of mindfulness and positive fantasizing as intervention techniques for reducing recurrence risk. BMC Psychiatry, 24, 107. https://doi.org/10.1186/s12888-024-05592-8
  • Bockting, C. L. H. (2025). Preventive Cognitive Therapy for Depression: An Evidence-Based Approach to Reduce Relapse Risk. Guilford Press.