COGNITIVE THERAPYOFDEPRESSION Dr. Reham Abdel-Samie Aly MD Psychiatry Fellow of Arab Board of Psychiatry Academy of Cognitive Therapy Diplomate & Member
The BeginningA ARON T. BECKA. JOHN RUSHBRIAN F. SHAWGARY EMERY
Introducing the authors “The early origins of my formulations regarding cognitive therapy of depression are not completely clear to me at present. As far as I can recall the first stirrings became manifest in my venture beginning in 1956 to validate certain psychoanalytic concepts of depression. I believed that these psychoanalytic formulations were correct but had failed to gain wider acceptance because of certain natural "resistances" of the academic psychologists and psychiatrists, attributable, in part, to the lack of supporting empirical data.
Contents of the Book 1. An Overview 1 2. The Role of Emotions in Cognitive Therapy 34 3. The Therapeutic Relationship: Application to Cognitive Therapy 45 4. Structure of the Therapeutic Interview 61 5. The Initial Interview 87 6. Session by Session Treatment: A Typical Course of Therapy 104 7. Application of Behavioral Techniques 117 8. Cognitive Techniques 142 9. Focus on Target Symptoms 167 10. Specific Techniques for the Suicidal Patient 209 11. Interview with a Depressed Suicidal Patient 225 12 Depressogenic Assumptions 244 13. Integration of Homework into Therapy 272 14. Technical Problems 295 15. Problems Related to Termination and Relapse 317 16. Group Cognitive Therapy for Depressed Patients 17. Cognitive Therapy and Antidepressant Medications 354 18. Outcome Studies of Cognitive Therapy
Roots of CBT The work of Ellis (1957, 1962, 1971, 1973) provided a major impetus in the historical development of CBT. Ellis links the environmental or Activating event (A) to the emotional Consequences (C) by the intervening Belief (B). Rational-Emotive Psychotherapy aims at making the patient aware of his irrational beliefs and the inappropriate emotional consequences of these beliefs. Rational-Emotive Psychotherapy is designed to modify these underlying irrational beliefs.
Philosophical Origins "Men are disturbed not by things but by the views which they take of them." Epictetus Symptoms & affect are based on unconscious ideas. Freud “We do not suffer from the shock of our experiences—the so-called trauma—but we make out of them just what suits our purposes.” Alfred Adler A number of other writers whose work emerged from or was influenced by the psychoanalytic tradition have contributed important concepts to the development of cognitive psychotherapy; Sullivan (1953), Piaget (1947/1950, 1932/1960) , Arnold Lazarus (1972)
General Assumptions1. Perception & experiencing are active processes which involve both inspective & introspective data.2. The patients cognitions represent a synthesis of internal & external stimuli.3. How a person appraises a situation is generally evident in his cognitions .4. These cognitions constitute the persons "stream of consciousness", which reflects the persons configuration of himself, his world, his past & future.5. Alterations in the content of the persons underlying cognitive structures affect his or her affective state & behavioral pattern.6. Through psychological therapy a patient can become aware of his cognitive distortions.7- Correction of these faulty dysfunctional constructs can lead to clinical improvement.
A N OVERVIEW SECTION I
The Cognitive Model of DepressionBeck, 1976
The Cognitive Model of Depression From systematic clinical observations & experimental testing. (Beck 1963,1964,1967) Interplay of a clinical & experimental approach allowed for a progressive development of the model & of the psychotherapy derived from it. Postulates 3 specific concepts to explain depression; Cognitive triad Schemas Cognitive errors (faulty information processing).
The Cognitive Triad3 major Cognitive Patterns which guide the patient inhis view of himself, his current experiences & hisfuture.
1st Patient’s negative view of self Sees himself defective, inadequate, diseased or deprived. Attributes unpleasant experiences to psychological, moral or physical defect. Believes he lacks essential attributes to attain happiness & contentment.
2nd patients tendency to interpret ongoing experiences in a negative way “The world present obstacles in reaching his goals”. Misinterprets interactions as representing defeat/deprivation.
3rd Negative view of the future Anticipates that his suffering is indefinite. Expects unremitting hardship, frustration & deprivation. Expectation of failure.
Cognitive formulation of depressivesymptomsClinical Application The cognitive model views signs & symptoms of the depressive syndrome as consequences of the activation of the negative cognitive patterns. For example, if the patient incorrectly thinks he is being rejected, he will react with the same negative affect (e.g., sadness, anger) that occurs with actual rejection. If he erroneously believes he is a social outcast, he will feel lonely.
Motivational symptoms Paralysis of the will results from the patients pessimism & hopelessness: If he expects a negative outcome, he will not commit himself to a goal or undertaking. Suicidal wishes: as an extreme expression of the desire to escape from insoluble problems or an unbearable situation. The depressed person may see himself as a worthless burden & consequently believe that everyone, himself included, will be better off when he is dead.
Increased dependency Because the patient sees himself as inept & helpless & unrealistically overestimates the difficulty of normal tasks, he expects his undertakings to turn out badly. Thus, the patient tends to seek help & reassurance from others, whom he considers more competent & capable.
Physical symptoms Apathy & low energy may result from the patients belief that he is doomed to failure in all efforts. A negative view of the future (a sense of futility) may lead to "psychomotor inhibition."
The Cognitive Model of DepressionSchemas(Structural Organization of Depressive Thinking)
Schemas Why a depressed patient maintains his pain- inducing & self-defeating attitudes despite objective evidence of positive factors in his life?! The term "schema" designates stable cognitive patterns. It is the basis for molding data into cognitions. The Matrix The kinds of schemas employed determine how an individual will structure different experiences.
Schemas (cont.) Schema may be inactive for long periods of time but is energized by specific environmental inputs (e.g., stressful situations). In depression, patients conceptualizations of specific situations are distorted to fit the prepotent dysfunctional schemas. Appropriate schema is upset by the intrusion of overly active dysfunctional idiosyncratic schemas. As these idiosyncratic schemas become more active, they are evoked by a wider range of stimuli which are less logically related to them till the patient loses his voluntary control over his thinking processes & is unable to invoke other more appropriate schemas.
Schemas Situation Stimuliselective attention specific stimuliConceptualization
Cognitive symptoms & SchemasClinical Application Schemas idiosyncratic completely dominates thinking preoccupation with preservative , repetitive –ve thoughts inability to concentrate on external stimuli e.g. reading or engage in voluntary mental activity e.g. problem solving & recall. I.e. the Idiosyncratic Cognitive Organization has become Autonomous & independent to external stimuli.
The Cognitive Model of DepressionFaulty Information Processing
Faulty Information Processing Systematic errors in the thinking of the depressed person maintain the patients belief in the validity of his negative concepts despite the presence of contradictory evidence. Include: Arbitrary Inference Selective Abstraction Overgeneralization Magnification & Minimization Personalization Absolutistic, Dichotomous Thinking (
Types of Faulty Information Processing Arbitrary Inference ; Selective abstraction ; drawing a conclusion in consists of focusing on a the absence of evidence detail taken out of to support the context, ignoring other conclusion or when the more salient features of evidence is contrary to the situation & the conclusion. conceptualizing the whole experience on the basis of this fragment. a response set a stimulus set
Types of Faulty Information Processing(cont.) Overgeneralization; Magnification & drawing a general rule or minimization; conclusion on the basis errors in evaluating the of one or more isolated significance or incidents & applying the magnitude of an event concept across the that are so gross as to board to related & constitute a distortion. unrelated situations. a response set a response set
Types of Faulty Information Processing(cont.) Personalization ; Absolutistic proclivity to relate external (dichotomous thinking); events to oneself when tendency to place all there is no basis for experiences in one of two making such a connection. opposite categories; for example, flawless or defective, immaculate or filthy, saint or sinner. In a response set describing himself, the patient selects the extreme negative categorization. a response set
Thinking disorder in depression Depressed persons are prone to structure their experiences in relatively primitive ways. “Primitive" vs. “Mature" modes of organizing reality.
Thinking disorder in depressionPrimitive thinking Mature thinking Non-dimensional & Global; Multidimensional. I am fearful. I am moderately fearful, quite generous, & fairly intelligent. Absolutistic & Moralistic; Relativistic & non-judgmental. I am a coward. I am more fearful than most people I know. Invariant; I always have been & always Variable; will be a coward. My fears vary from time to time & from situation to situation. “Character Diagnosis”; “Behavioral Diagnosis”; I have a defect in my character. I avoid situations too much & I have many fears. Irreversibility ; Since I am basically weak, Reversibility; theres nothing that can be done I can learn ways of facing situations & fighting my fears. about it.
The Cognitive Model of DepressionPredisposition to & Precipitation of Depression
The Cognitive Hypothesis
The Cognitive Model of DepressionA Reciprocal Interaction Model“A person’s behavior influences other people whoseaction in turn influence the individual”. Bandura 1977
The Reciprocal Interaction Model A person slipping into depression may withdraw from significant other people. Thus alienated, the "significant others" may respond with rejections or criticisms, which in turn, activate or aggravate the persons own self-rejection & self- criticism. The resulting negative conceptualizations lead the patient to further isolation. Thus the vicious cycle can continue until the patient is so depressed that he may be impervious to attempts by others to help him & show him love & affection.
Prerequisites for Conducting CT1- Know your enemy.2- Expect the worst.3- Master your craft.4- Be genuine.
1- Know your enemy Must have a solid understanding of the clinical syndrome of depression. “Treat the patient rather than the disorder”?!! 1- specific symptoms to differentiate from different disorders. 2- has a particular course. 3- lethal complication (suicide). 4- successful somatic treatment (psychopharmacology & ECT). 5- body of evidence favors a biological derangement. 6- a strong hereditary determinant. 7- specific cognitive distortions & underlying assumptions. 8- determine the ppt factor (actual or imagined loss vs. threat or danger).
Warning Inexperienced clinician may fix his attention on one facet of depression & ignore others e.g. associated psychotic symptoms & proudly report a change in one area e.g. improved interpersonal relations, increased activity level, or an apparent reduction of sadness. Within a few days the patient committed SUICIDE.
2- Recognize the suicidal patient Even a mildly depressed patient may commit suicide. Suicide is NOT uncommon during psychotherapy. Act fast: Notify patient’s family Hospitalization Medication & ECT Prompt psychological intervention.
3- Master your craft The aspiring cognitive therapist must be 1st a good psychotherapist. Necessary characteristics: Have the capacity to respond to your patient with concern, acceptance & sympathy. Therapists with diverse backgrounds can successfully conduct CBT e.g. Psychodynamic; empathetic, sensitive & skillful. Behavioral therapists; well qualified in BT techniques
4- Be genuine To achieve good results in CBT be knowledgeable, warm, empathetic, accepting, have a clear understanding of the cognitive model of depression, grasp the concept of CT . Earn formal training including supervision; a range of six months training to 2 years is enough to reach criteria of competency.
Limitations of CT
Limitations of applicability Specific kinds of depression. Presence of ‘borderline’ characteristics. Patient’s characteristics; Educational level, Attitudes towards psycho- vs. pharmaco-therapy, Psychological-mindedness, Ego-strength.
Warning Therapy should be confined to the kinds of patients who have been shown by research studies to be responsive to this approach. Effectiveness of therapy was demonstrated with ONLY unipolar, nonpsychotic, depression. For severe or bipolar or suicidal patients apply standard procedures (hospitalization & somatic therapy).
Warning (cont.) When is CBT preferable to medication: Patient refusing medication, Prefers psychological approach in hope that it will reduce his proneness to depression, Has unacceptable side effects or C.I. to medication, Has proven refractory to somatic treatments.
Common Pitfalls in Learning CTCommon defects & errors in the therapeuticapproach of trainees!
1- Slighting the therapeutic approach Forgets the importance of establishing a sound therapeutic relationship with the patient. The therapist must never lose sight of the fact that he is engaged with another human being in a very complicated task.
Safeguard Be particularly sensitive to: a. The importance of discussion & expression of the patients emotional reactions. b. The patients own habitual style of communicating. c. be very active at times & relatively restrained at others. d. some patients require considerable coaching, others require encouragement to take the initiative.
2- Being Stylized, Erratic, or OverlyCautious Trainees may be so eager to master the technical aspects that they parrot their role models ("The Masters") instead of integrating the therapeutic approach into their own natural style. At the other extreme, the therapist may stretch the elasticity of the cognitive model to "try out" whatever particular techniques appeal to him without regard to their appropriateness for this particular patient at this particular time.
Safeguard Obtaining feedback from the patient regarding his understandings of the therapists communications & any counterproductive reactions he may have to the therapists manner, techniques, or suggestions .
3- Being Overly Reductionist & Simplistic Many trainees believe cognitive therapy involves only getting people to recognize & correct their negative thinking. The inexperienced therapist may attempt to conduct therapy "from a cookbook."
Safeguard The therapist needs to tread the line between being overly concrete & overly abstract; atomistic vs. global. Cognitive therapy is a holistic approach but it is applied in a sequence of discrete, readily understandable steps.
4- Being Overly Didactic or ExcessivelyInterpretive The use of questions is an important part of cognitive therapy. It may be easy for the therapist to point out that the patient has distorted his experiences, that there is an intervening thought between an event & an emotional experience. But very little progress may occur.
Safeguard Ask questions that open up the patients closed logic by using an inductive approach. Encourage the patient to practice a self-questioning behavior later when he is without a therapist e.g. "What is the evidence?" "What is the most adaptive thing for me to do right now?" Enable the patient to learn to recognize & test his hypotheses, to develop a healthy empiricism that serves as a safeguard against forming unrealistic conclusions. Assume an educative role with the patient e.g. to explain characteristics of depression & cognitive therapy.
5- Reacting Negatively to DepressedPatients working with depressed patients is often hard, tedious work. get caught up in the patients belief that his life is hopeless & thus give up on the patient. label the patient as being resistant & make a motivational interpretation of the patients behavior & thus react to the patient on the basis that he is being manipulated.
Safeguard Attempt to empathize with the patient. Understand the patients "resistance" as inevitable consequence of the way he constructs reality.
6- Accepting “Intellectual Insight” To be misled by the patients statements that he believes the therapists formulations "intellectually" but not "emotionally." What is "real" to the patient is his own belief—not the therapists declarations. When an individual holds an important belief, he usually "trust" his subjective feeling that the belief is right.
Safeguard Allow the patient to gradually integrate the therapists idea into his belief system. This is accomplished best through Empirical (practical) Demonstration.
Maximizing the Impact of CT
1- Importance of CollaborativeEnterprise with the Patient The more the therapist & patient work together, the greater the learning experience for both. The joint effort engenders a cooperative spirit & a sense of exploration & discovery. This enhance motivation & help to overcome the many obstacles.
2- Value of Capitalizing on the Variations &Fluctuations in the Patient’s Depression When the patient shows an improvement, the therapist should encourage him to pinpoint what methods (if any) contributed to the improvement. Exacerbations of symptoms or relapses should be anticipated and "welcomed" as a valuable source of information for exploring the factors leading to intensification of depression and a valuable opportunity for the patient to practice his techniques for dealing with these problems. “Turn every disadvantage into an advantage."
3- Continuing Emphasis on Self-Exploration The concentration on exploring the meaning of events throughout the course of therapy &, especially, after termination, should be encouraged.
4- “State-Dependant Learning” Patients learn best to analyze & deal with their difficulties when their problems are "hot." What a person learns in a particular state is more likely to generalize to that specific state than to other states. For this reason, it is sometimes advisable to attempt to "recreate" a quiescent situation during a therapy session.
5- Collaboration of SignificantOthers Sometimes the active collaboration of a family member or friend may be indicated. The "auxiliary therapist" can be trained to implement specific therapeutic strategies in the home situation.
End of Section I
A TYPICAL COURSE OF THERAPY SECTION II
OVERVIEW Initially, the therapist presents a rationale for cognitive therapy & discuss the patients reaction to the model. Prior to the first treatment session, the therapist send the patient a booklet about Depression, with a request that she read it to assist with this aspect of treatment. Therapy then center on the patients symptoms with initial attention to behavioral & motivational difficulties. Then emphasis is directed to the content & pattern of the patient’s thinking.
OVERVIEW (cont.) In the later sessions, therapist & patient discuss the basic assumptions that were viewed as resulting in the patient’s vulnerability to depression. Experience indicates that the moderately to the severely depressed patients require twice-weekly sessions initially. The frequency and duration of therapy has to be adjusted to the needs of the individual case; Protocol call for a maximum of 20 sessions over a 15-week period. On the average, patients receive therapy twice a week for 4 weeks & then once a week for 7 weeks. Therapist should be flexible in "tapering off therapy (e.g., to bi- weekly, monthly, etc.).
THE INITIAL INTERVIEW
Eliciting Essential InformationElicit information regarding the patients; (a) diagnosis, (b) past history, (c) present life situation, (d) psychological problems, (e) attitudes about treatment, & (f) motivation for treatment.Give the patient some objectivity regarding the particular disorder. This objectivity in itself is often quite reassuring.
Mental Status Examination It is crucial that the therapist make appropriate evaluation as to: whether or not the patient is psychotic. whether the patient is suicidal. "organic" problems such as brain damage, physical illness simulating depression, mental deficiency, etc. Thus therapist needs to have a strong grounding in psychiatric evaluation & diagnosis & a reasonable knowledge of medical disorders.
Therapeutic Goals of the InitialInterview A main therapeutic goal of the first interview is to produce at least some relief of symptoms; Reduce patient’s suffering, Satisfies the therapists desire to help another person in a meaningful way. The symptom relief helps to increase rapport, therapeutic collaboration, & confidence in the efficacy of the therapy. Make the patient more optimistic & the reinforcing effect of having "worked through" a particular problem. Stimulates the patient to do his homework between sessions.
Therapeutic Goals of the InitialInterview (cont.) The most effective way to reach the immediate therapeutic goal & provide a rational basis for reassurance is to attempt to define a set of problems & demonstrate to the patient some strategies for dealing with these problems. The technical application of the strategies should (ideally) begin during the interview &, be carried out by the patient after the interview is completed. Any "success experience" by the patient— even achievement of the task of isolating a problem & viewing it objectively during the interview—is likely to give him an increased sense of mastery.
Selecting Target Symptoms The target symptom is “any of the components of the depressive disorder that involves suffering or functional disability”. It is difficult to stipulate in advance which problems should be selected during the first interview . The therapist (with the assistance of the patient) makes a determination as to which of the target symptoms should be addressed on the basis of many factors: a. Which are the most distressing to the patient? b. Which are most amenable to therapeutic intervention?
Selecting Target Symptoms (cont.) Target symptoms may be broken down into the following categories ; Affective symptoms: sadness, loss of gratification, apathy, loss of feelings and affection toward others, loss of mirth response, anxiety. Motivational: wish to escape from life (usually via suicide); wish to avoid "problems" or even usual everyday activities. Cognitive: difficulty in concentrating, problems in attention span, difficulties in memory. The cognitive distortions— which are more on a conceptual or information-processing level. Behavioral: passivity (e.g., lying in bed or sitting in a chair for hours on end), withdrawal from other people, retardation, agitation. Physiological or vegetative: sleep disturbance (either increased or diminished sleeping); appetite disturbance (either increased or decreased eating).
Translating "Chief Complaint" into"Target Symptom" "I want to divorce my husband." Patient see all her relationships & interactions in absolutistic, black-and-white terms. She could only see the negative features in her spouse—& in fact, exaggerated these features. she interpreted the loss of feeling toward her husband as a sign that her love for him was irreversibly lost. In fact, when not depressed, she had a happy, fulfilling relationship with her husband. "I have no feeling." patients interpret lack of affective response as a sign that they have undergone a permanent transformation. Patients do not see these symptoms as aspects of depression but rather as signs of some irreversible change in their personality.
Translating "Chief Complaint" into"Target Symptom” (cont.) "I cannot handle my problems." patient greatly exaggerated some of her interpersonal difficulties & at the same time underestimated her coping abilities. As a result of such negative evaluations of herself, her confidence eroded further. a vicious cycle was established that progressively undermined her capacity to master situations. "I am a terrible person." The patient interpreted symptoms of depression (such as slowing down, difficulty in concentrating, loss of affection for her family) in the typical negative, moralistic way seen among depressed patients. She viewed these symptoms as indicating that "I am lazy and self- centered; I dont care about anybody but myself."
Feedback in the Initial Interview(cont.) The feedback may be obtained in a number of ways as follows: 1. The therapist summarizes the patients narrative or extracts the major problems. For example, one-third of the way through an initial interview, the therapist capsulizes the patients problem. 2. To make sure that the patient is really "tuned in" to the therapists summary of conceptualizations, he should ask the patient what he or she abstracts from the therapists statements.
Feedback in the Initial Interview Of the utmost importance ! Consists not only of the observation of the patients overt emotional responses during the interview but also explicit statements by the patient of his reaction to the therapist & the therapy process itself. Reciprocal feedback is important in establishing (a) whether the therapist understands the patients problem & (b) whether the patient understands what the therapist is saying.
Feedback in the Initial Interview(cont.) The feedback may be obtained in a number of ways as follows: 1. The therapist summarizes the patients narrative or extracts the major problems. For example, one- third of the way through an initial interview, the therapist capsulizes the patients problem. 2. To make sure that the patient is really "tuned in" to the therapists summary of conceptualizations, he should ask the patient what he or she abstracts from the therapists statements.
Feedback in the Initial Interview(cont.) 3. The third type of feedback has been alluded to previously. The therapist tries to elicit covert reactions to the interview that may be counterproductive. If there is any sign of "static" in the interview, it is desirable for the therapist to inquire as to what the patient is thinking. 4. Similarly, after proposing a homework assignment, the therapist can say to the patient, "How do you feel about this assignment? Do you feel that it is something that you would like to tackle, or does it seem onerous to you. Or would you prefer to think about it?“ By giving the patient a multiple choice, as it were, the therapist is more likely to get a genuine response from the patient.
Feedback in the Initial Interview(cont.) 5. Finally, it is important for the therapist to get some feedback sometime during the first part of a subsequent interview regarding the patients reactions to the previous interviews; that is, reactions that had occurred following the termination of the interview. This would also be a good time to get the patients possible negative reactions to the homework assignments.
1. The therapist treating depressed patients requires a solid background in psychopathology and diagnosis. 2. Interview should be geared to establish: a. A therapeutic working relationship, including rapport b. Consensus on goals and treatment procedures c. Collaboration in defining and "solving" problems d. Appropriate interchange to provide optimum feedback to both patient and therapist regarding reciprocal understanding, stumbling blocks in therapy, progress toward goals, etc. 3. The therapist should attempt to utilize technical procedures to provide some symptom of relief in the first session as well as in subsequent sessions. A mechanism for maintaining symptom relief needs to be set up to utilize the time between sessions optimally (for example, homework assignments, listening to a tape recording of the previous therapy session, etc.).
4. The ideal way to motivate the patient to work on his problems is to produce prompt lessening of symptoms through working together on particular problems. Thus, "education" or "reeducation" is preferable to prestige suggestion or authoritarian reassurance. 5. The therapist should work within the arbitrary time constraints of the interview to achieve several concomitant technical goals: a. Establish a diagnostic profile b. Assess the degree of psychopathology c. Estimate the patients assets for therapy and his social support system d. Obtain a solid data base in order to formulate the patients problems. This involves setting up and testing a hierarchy of hypotheses. e. Improvise and test out a variety of treatment strategies appropriate for the particular stage of therapy. 6. Utilizing time optimally may involve diplomatically interrupting the patient when he rambles and guiding him back to focusing on his problem.
AN OUTLINE OF SESSIONS
Session 1 (BDI= 41)Plan (Agenda) Assigned Homework Review symptoms of Keep activity schedule: to depression. ascertain how active the patient is & to obtain Assess suicidal ideation & "objective" data about her hopelessness. present level of functioning. Discuss influence of Complete MMPI (to evaluate degree of psychopathology thinking on behavior with as well as obtaining research specific reference to data). depression. Complete Life History Review activity level. Questionnaire to obtain relevant past history.
Session 2 (BDI= 43)Plan (Agenda) Assigned Homework Review symptoms of Continue with activity depression. schedule with patients Review activity schedule agreeing to attempt checking for possible mastery &/or pleasure omissions & distortions. activities. Begin to demonstrate Define problems that relationship between patient sees as thinking, behavior & affect contributing to her by using specific depression. experiences of patient.
Session 3 (BDI=38)Plan (Agenda) Assigned Homework Review "Mastery & Record cognitions during Pleasure" activities. periods of sadness, Continue to elicit thoughts anxiety, & anger & during related to sadness. periods of "apathy," in order to elicit the relationship between thinking, behavior, & affect.
Session 4 (BDI=31)Plan (Agenda) Assigned Homework Discuss specific cognitions Continue recording cognitions—if possible, leading to unpleasant record alternative affect. explanations; avoid labels such as "incompetent" and "selfish" since these pejorative terms serve to disguise problems. Rate on a scale of 0-10 the degree to which she "wanted to complete the activities" as opposed to meeting the therapists or her husbands expectations.
Session 5 (BDI=36)Plan (Agenda) Assigned Homework Discuss cognitions & "Beds are for sleeping." If identify recurrent or not asleep in 15 minutes, common themes. get up & do something to distract thinking. Continue to record thoughts & list responsibilities to husband & vice versa.
Session 6 (BDI=29), session 7(BDI=26), session 8 (BDI=26)Plan Homework Review cognitions, Continue to recognize particularly her cognitive errors and review expectations for herself & alternative explanations her "shoulds" rather than for her negative "wants." "automatic thoughts." Discuss her thoughts regarding her marital responsibilities.
Session 9 (BDI=23), session 10(BDI =22), session 11 (BDI=30) Focus on self-criticisms & work on coping Plan Homework responses (that is, realistic evaluations of problem areas rather than self-criticisms). Pursue responding to her "wants" rather than her "shoulds." ; assertiveness discussions time management & future planning
Session 12 (BDI=15), session 13 (BDI=20),session 14 (BDI=17), session 15 (BDI=17)Plan Homework Continue to attend to self- List "wants," particularly criticisms with focus on future goals. underlying assumptions. This assignment focus the Assess the basis for patient on his own needs & patient’s unrealistic self- criticisms & other expectations. depressive reactions. Investigate the patients attitudes & beliefs that contributed to his depression.
Session 16 (BDI=22), session 17 (BDI=18),session 18 (BDI=12), session 19 (BDI= 14)Plan Homework Review the similarities Discuss goals with husband between the patient’s in greater detail with present reaction & past particular reference to pattern of thinking. homemaking responsibilities. These interchanges were highly significant to help the patient regain motivation to pursue a reasonable course of action.
Session 20 (BDI=8), session 21(BDI=6), session 22 (BDI=7) These final sessions attempt to consolidate the gains made in therapy.
Follow Up: 1 month (BDI=9); 2months (BDI=5); 6 months (BDI=2) During the follow-up period help the patient remain non-depressed & note with considerable pleasure being more confident. The patient "old automatic thoughts" would still be elicited but he remains convinced that the best approach to this ideation was a careful reappraisal of the situation.
TECHNIQUES OF CBTFocus on the details
BEHAVIORAL TECHNIQUESCognitive Change through Behavioral Change;Behavioral techniques improve level of functioning,counteract obsessive thinking, change dysfunctionalattitudes, & give a feeling of gratification.By observing changes in his own behavior, thepatient may then be more amenable to examininghis negative self-concept.An amelioration of the negative self-concept thenleads to more spontaneous motivation & animprovement in mood.
Scheduling Activities A "graded task" hierarchy. Prescription of projects based on the clinical observation that depressed patients find it difficult to undertake or complete jobs which they accomplished with relative ease prior to the depressive episode. To counteract the patients loss of motivation, inactivity, & his preoccupation with depressive ideas. An hour-by-hour basis to maintain a certain momentum & prevent slipping back into immobility. Focus on specific goal-oriented tasks to provide the patient & therapist with concrete data on which to base realistic evaluations of the patients functional capacity. The therapist should present the patient with a rationale “inactivity increases negative ruminations & dysphoria”.
Scheduling Activities (cont.)
Mastery & Pleasure TechniquesPatients engage in activities but derive little pleasure from them from either(a) an attempt to engage in activities which were not plesurable even prior to the depressive episode,(b) the dominance of negative cognitions which override any potential sense of pleasure, or(c) selective inattention to sensations of pleasure.
Mastery & Pleasure Techniques(cont.) Assign the task of undertaking a particular pleasurable activity for a specified number of minutes each day & request that the patient note changes in mood or reduction of depressive ruminations associated with the activity. Make the patient record the degree of Mastery (M) & Pleasure (P) associated with the activity. Mastery refers to a sense of accomplishment when performing a specific task. Pleasure refers to pleasant feelings associated with the activity. Mastery & Pleasure can be rated on a 5-point scale with 0 representing no mastery (pleasure) and 5 representing maximum mastery (pleasure).
Mastery & PleasureClinical Application While severely depressed, a 38-year-old executive returned his Activity Schedule with the following ratings of Mastery & Pleasure on a 0-5 scale. Saturday MP 8-9 a.m. Awoke, dressed, ate breakfast 1 1 9-12 noon Wallpaper kitchen 0 0 12-1 p.m. Lunch 0 0 1-3 p.m. Watched TV 0 0 The report indicates that although breakfast provided some pleasure & just getting up was rated as achievement, the remainder of the day provided no sense of pleasure or mastery. Yet the patient did wallpaper a kitchen while very depressed.
Mastery & PleasureClinical Application (cont.)How did he discredit this apparent achievement?Therapist: Why didnt you rate wallpapering the kitchen as a mastery experience?Patient: Because the flowers didnt line up.T: You did in fact complete the job?P: Yes.T: Your kitchen?P: No. I helped a neighbor do his kitchen.T: Did he do most of the work? (Note that the therapist inquires about any other reasons for a sense of failure which might not be offered spontaneously.)P: No. I really did almost all of it. He hadnt wallpapered before.T: Did anything else go wrong? Did you spill the paste all over? Ruin a lot of wallpaper? Leave a big mess?P; No, no, the only problem was that the flowers did not line up.T: So, since it was not perfect, you get no credit at all.P: Well . . . yes.
Mastery & PleasureClinical Application (cont.)T: Just how far off was the alignment of the flowers?P: (holds out fingers about Vb of an inch apart): About that much.T: On each strip of paper?P: No ... on two or three pieces.T: Out of how many?P: About 20-25.T: Did anyone else notice it?P: No. In fact, my neighbor thought it was great.T: Did your wife see it?P: Yeh, she admired the job.T: Could you see the defect when you stood back and looked at the whole wall?P: Well . . . not really.T: So youve selectively attended to a real but very small flaw in your effort to wallpaper. Is it logical that such a small defect should entirely cancel the credit you deserve?P: Well, it wasnt as good as it should have been.T: If your neighbor had done the same quality job in your kitchen, what would you say?P: ... pretty good job!
Graded Task Assignment(Goldfried, 1974)key features of the Graded Task Assignment are: 1. Problem definition—for example, the patients belief that he is not capable of attaining goals that are important to him. 2. Formulation of a project. Stepwise assignment of tasks (or activities) from simpler to more complex. 3. Immediate & direct observation by the patient that he is successful in reaching a specific objective (carrying out an assigned task). The continual concrete feedback provides the patient with new corrective information regarding his functional capacity. 4. Ventilation of the patients doubts, cynical reactions, & belittling of his achievement. 5. Encouragement of realistic evaluation by the patient of his actual performance. 6. Emphasis on the fact that the patient reached the goal as a result of his own effort and skill. 7. Devising new, more complex assignments in collaboration with the patient.
Graded Task AssignmentClinical example The therapist visited a 40-year-old woman patient on the first day of her hospitalization. She was lying in her bed, ruminating about her problems and "feeling miserable." The therapist was able to determine that in the past, she had enjoyed reading. She stated, however, "I havent even been able to read a headline in a newspaper for the past couple of months." The therapist selected the shortest story in a collection from the library & urged her to read it while he was with her. She said, "I know I wont be able to read it." He replied, "Well, try reading the first paragraph out loud." She responded, "I may be able to mouth the words but I wont be able to concentrate." He then suggested, "See whether you can read the first sentence." She read the first sentence aloud and continued until she had completed the paragraph. He asked her to read some more but to try reading to herself. She gradually became engrossed in the short story & spontaneously continued onto the next page. He told her to keep reading and that he would return later. About an hour later, the therapist observed that her depression had indeed lifted (temporarily). He encouraged her to undertake a regimen of reading progressively longer short stories; by the end of the week, she was reading a long novel. Within ten days after admission and with continued treatment, she was well enough to return home.
Cognitive Rehearsal “asking the patient to imagine each successive step in the sequence leading to the completion of the task”. Forces the patient to pay attention to the essential details of the activities & counteracts the tendency of his mind to wander. patient has a preprogrammed system to carry out the assignment. identify potential "roadblocks" (cognitive, behavioral, or environmental) which might impede the achievement of the assignment. Some patients report that they feel better simply as a result of the completion of the assigned task in imagery.
Cognitive RehearsalClinical example The patient was a 24-year-old single unemployed female who after some discussion agreed to attempt to attend her neglected exercise classes. Therapist: So you agree that it would be a good idea to go to an exercise class. Patient: Yes, I always feel good after them. T: Okay, well Id like you to use your imagination and go through each step involved in getting to the class. P: Well, Ill just have to go the way Ive always gone. T: I think we need to be more specific. We know that youve decided to go to class before but everytime youve run into some roadblocks. Lets go over each step and see what might interfere with getting to class. Id like you to go through all the steps needed to get to your class. Go over each step in your imagination and tell me what they are. P: Okay. I know what you mean.
Cognitive RehearsalClinical example (cont.) T: The class starts at 9 a.m. What time should we start? P: About 7:30. Ill wake up to the alarm and probably be feeling lousy. I always hate starting the day. T: How can you handle that problem? P: Well, thats why Ill give myself extra time. Ill start by getting dressed and having breakfast. Then, Ill pick up my equipment . . . (pause) . . . Oh, oh, wait, I dont have a pair of shorts to wear. Thats one roadblock. T: What can you do to solve that problem? P: Well, I can go out and buy some. T: Can you visualize that? What comes next? P: I picture myself all ready to go and the car isnt there. T: What can you do about it? P: Ill ask my husband to bring the car early. T: What do you picture next? P: Im driving to the class and I decide to turn round and go back. T: Why? P: Because I think Ill look foolish. T: Whats the answer to that? P: Well, actually, the other people are just interested in the exercise, not in how anybody looks.
Assertive Training & Role-Playing Training of specific skills using techniques as modeling, coaching, & behavior rehearsal. Role-playing involves the adoption of a role by the therapist, the patient, or both, and the subsequent social interaction based on the assigned role. the therapist attempts to clarify self- defeating or interfering cognitions.
Rationale & Timing of BT Depressed patients are prone to distort the purpose of the tasks post facto. It is the therapists responsibility to insure that the patient interprets the results of an assignment within the confines of the initial objective. The initial objective, therefore, must be made clear from the beginning.
Rationale & Timing (cont.) To evaluate the patients understanding of a task is to use a role-reversal. The utilization of a "significant other" (spouse, other relative, or close friend) is often very helpful in setting & implementing behavioral assignments. Appropriate targets of behavioral techniques include passivity, avoidance, lack of gratification, & an inability to express appropriate emotions (such as anger and sadness).
Rationale & Timing (cont.) Homework assignments also need to be graded to the patients level of understanding. In general, homework is not assigned until the patient completes a form of the assignment in the session. Telephone conversations between patient and therapist; the agreement to call the therapist when the patient is "stuck" in carrying out an assignment is very helpful. This practice enables the patient to identify and master his problems in the "real life situation" and also motivates him to continue with his assignments. "Reporting in" to the therapist by telephone when the patient has completed a series of assignments also provides a powerful motivation to carry out the projects.
Rationale & Timing (cont.) Once the patient understands the rationale and application of the behavioral techniques, therapy proceeds to more "purely" cognitive approaches. If behavioral symptoms or problems reappear, the patient may need a "refresher course" or may simply reinstitute the behavioral techniques. In times of stress, many former patients return to activity scheduling or recording. Since the techniques have already been mastered, they are easily used to prevent incipient regression.
COGNITIVE TECHNIQUESBe aware of the fact that many depressed patients are sopreoccupied with negative thoughts that further introspectionmay aggravate the perseverating ideation.
The Influence of Cognitions onAffect & Behavior to demonstrate the relationship between thinking and affect use the "induced imagery" technique; The therapist first asks the patient to imagine an unpleasant scene. If the patient indicates a negative emotional response, the therapist can inquire about the content of the patients thoughts. The therapist then asks the patient to imagine a pleasant scene and to describe his feelings. Typically, a patient is able to recognize that by changing the content of his thought he is able to alter his feeling state.
Cognition & Recent Experiences Demonstrate to the patient the presence of cognitions in his sphere of awareness. it is essential for the patients to become aware of & to identify their negative cognitions.
The 5 areas of CBT
Detection of Automatic Thoughts Assign a specific project designed to delineate the patient’s dysfunctional cognitions; the patient is instructed to "catch" as many cognitions as he can and to record them in writing. the patient can use changes in affect or the experience of dysphoria as a marker or cue to recognize or recall his cognitions. Direct the patient to set aside a specific brief period of time, for example, 15 minutes each evening, to replay the events that led to his cognitions.
The ABC of CBT
Recording Dysfunctional Thoughts Recording cognitions and responses in parallel columns to begin examining, evaluating, and modifying the cognitions. The patient writes his cognitions in one column and then write a "reasonable response" to the cognitions in the next column. The written assignment may also include additional columns for describing the patients affect and behavior, and the specific description of the situation or event which preceded the cognition. depending on the number of columns used, the technique may be referred to as the double-column, the triple-column, or even the quadruple-column technique. “The Daily Record of Dysfunctional Thoughts “ rationale for this approach is to teach the patient more precise discriminations of his emotions & to think of reasonable responses to his negative cognitions.
Recording Dysfunctional ThoughtsClinical example
Examining & Reality Testing AutomaticThoughts & Images Not to induce a spurious optimism by inducing him to think that "things are really better than they are," but to encourage a more accurate description & analysis of the way things are. Therapist should not fall into a trap of assuming that all of the patients pessimistic or nihilistic statements are necessarily invalid; examine a sample of the patients thoughts in collaboration with the patient. The basis or evidence for each thought should be subjected to the scrutiny of reality testing with the application of the kind of reasonable standards used by nondepressed people in making judgments.
Examining & Reality Testing Automatic Thoughts &ImagesClinical example For example, a depressed young student expressed the belief that she would not get into one of the colleges to which she had applied. When the therapist explored the reasons which led to her conclusion, he discovered there was little basis for it.T: Why do you think you wont be able to get into the university of your choice?P: Because my grades were really not so hot.T: Well, what was your grade average?P: Well, pretty good up until the last semester in high school.T: What was your grade average in general?P: As and Bs.T: Well, how many of each?P: Well, I guess, almost all of my grades were As but I got terrible grades my last semester.
Examining & Reality Testing Automatic Thoughts &ImagesClinical example (cont.) T: What were your grades then? P: I got two As and two Bs. T: Since your grade average would seem to me to come out to almost all As, why do you think you wont be able to get into the university? T: Because of competition being so tough. T: Have you found out what the average grades are for admissions to the college? P: Well, somebody told me that a B+ average would suffice. T: Isnt your average better than that? P: I guess so.
Reattribution Techniques Depressed patients are particularly prone to self- blame resulting from the negative consequences of events beyond their control as well as those relative to their actions and judgments. Used when the patient unrealistically attributes adverse occurrences to a personal deficiency, such as a lack of ability or effort. Not to absolve the patient of all responsibility but to define the multitude of extraneous factors contributing to an adverse experience.
Reattribution TechniqueClinical example The patient was a 51-year-old moderately depressed bank manager who complained primarily of "ineffectiveness in my job." By "ineffectiveness" the patient referred to a difficulty he experienced in making business decisions.
Reattribution TechniqueClinical example (cont.) P: I cant tell you how much of a mess Ive made of things. Ive made another major error of judgment which should cost me my job. T: Tell me what the error in judgment was. P: I approved a loan which fell through completely. I made a very poor decision. T: Can you recall the specifics about the decision? P: Yes, I remember that it looked good on paper, good collateral, good credit rating, but I should have known there was going to be a problem. T: Did you have all the pertinent information at the time of your decision? P: Not at the time, but I sure found out 6 weeks later. Im paid to make profitable decisions, not to give the banks money away. T: I understand your position, but I would like to review the information which you had at the time your decision was required, not 6 weeks after the decision had been made.
The Search for Alternative Solutions The depressed patients closed system of logic & reasoning opens as he distances himself from his cognitions and identifies the rigid patterns & themes of his thinking. At this point, the "search for alternatives" may prove useful. involves the active investigation of other interpretations or solutions of the patients problems. This approach forms the cornerstone of effective problem-solving.
Counteracting Automatic Thoughts
Use of the Wrist Counter After the patient correctly identifies faulty cognitions & distinguishes them from "normal," adaptive, or neutral thoughts. the therapist check regularly to insure that the patient is "checking" the kinds of cognitions of importance to the therapy “negative cognitions “: (1) They are automatic—they occur as if by reflex, without prior reasoning; (2) they are unreasonable & dysfunctional; (3) they seem completely plausible & are uncritically accepted as valid even though they seem bizarre upon reflection; (4)they are involuntary. The patient may have great difficulty in "turning them off." Each patient has his own idiosyncratic kind of automatic thoughts.