Cognitive Behaviour Therapy

A Guide for the Practising Clinician, Volume 1

Gregoris Simos, Gregoris Simos

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317822431
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Although Cognitive Behavioural Therapy (CBT) has a well elaborated theoretical background and documented standard therapeutic process, new specific theoretical formulations and genuine techniques seem to continually appear. These new treatment developments in CBT constitute the heart of this book.
Leading researchers and clinicians, who are also well established experts in the application of CBT present the extent of their experience, as well as appropriate and state-of-the-art treatment techniques for a variety of specific disorders:
* Management of Major Depression, suicidal behaviour and Bipolar Disorder.
* Treatment of Anxiety Disorders such as Panic Disorder, Obsessive Compulsive Disorder, and Generalized Anxiety Disorder.
* Application of CBT to Eating Disorder and Personality Disorders, especially Borderline Personality Disorder.
* Implementation of CBT with specific populations such as couples and families, children and adolescents.
The book focuses on clinical practice and treatment techniques, but avoids a step-by-step approach.
Instead it encourages flexibility and integrativity in order to help the practicing clinician become more competent and efficient in applying CBT. Well-known contributors reveal a variety of treatment styles, and case examples and treatment transcripts are used to show how theoretical innovations integrate with the practice of CBT.

Chapter 1

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The cognitive treatment of depression

Kevin T. Kuehlwein

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Impact of depression

Depression in its various forms (major depression, dysthymia, the depressed phase of bipolar disorder) is both a highly disabling and disturbingly widespread phenomenon in today's society. It causes huge suffering and economic costs to individuals and society because of both its high prevalence and its undertreatment among most segments of society (National Depressive and Manic-Depressive Association Consensus Statement on the Undertreatment of Depression (NDMACS); Hirschfeld et al., 1997). Moreover, although effective treatments for depression exist, various factors on both the client and professional side prevent people from recognising the signs of depression and then receiving optimal treatment from qualified professionals. Depressed individuals often feel the stigma attached to problems of “mental illness”. This makes them reluctant to seek help in the earlier stages of the disorder before certain of their negative cognitive-affective-behavioural patterns have strengthened. Instead of simply realising that they may need professional help, depressed clients often label themselves as “weak” or “failures” (or fear others may do so) due to their increasing difficulty in handling many aspects of their lives.

Recent studies on the impact of major depression have compared its negative effects to those of other chronic general medical ailments like heart disease, hypertension, and diabetes (Hays, Wells, Sherbourne, Rogers, & Spritzer, 1995). The monetary toll alone in the United Kingdom has been estimated at between £220 million (Jonsson & Bebbington, 1994) and £2500 million per year (including indirect costs) (Kind & Sorenson, 1995). Optimal treatment, furthermore, does not often occur because many professionals even in highly industrialised countries are themselves inadequately trained in both the diagnosis and treatment of depression, from both the psychotherapeutic as well as pharmacological angles. A few statistics will illustrate these points.

• The lifetime risk of major depression in the United States and other countries has been reported to range from about 5 to 25% in women and from 2 to 12% in men (Boyd & Weissman, 1981).

• Of those who are depressed and see a health professional, the vast majority do not even encounter a mental health professional, but instead are seen only by a primary practice doctor (Hirschfeld et al., 1997).

• Because certain physical disorders can involve symptoms similar to those of depression, many examining physicians do not accurately or promptly detect depression in the majority of their patients. Therefore, they often neither treat the concomitant depression nor refer the patient to a competent mental health professional (Hirschfeld et al., 1997).

• Costs of actual treatment combined with diminished productivity resulting from major depressive disorder in the United States total approximately $16 billion in 1980 dollars (Hirschfeld et al., 1997).

• People with three or more episodes of major depressive disorder have a 9 in 10 chance of having a relapse into a further episode (Hirschfeld et al., 1997).

Luckily, Beck's cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) has proved highly effective in many studies as a treatment for depression (Hollon & Beck, 1994). This chapter will focus primarily on the outpatient treatment of major depression in individual therapy with adults because the research has concentrated on that population. It is, however, possible to use this approach with milder types of non-psychotic depression and, with certain modifications, as an adjunct to pharmacotherapy with bipolar disorder clients. Indeed, therapists can use cognitive therapy with many clients on medications to increase their medication compliance. It has also been practised successfully in group formats (Hollon & Shaw, 1979; Freeman, Schrodt, Gilson, & Ludgate, 1993) and with children, again with certain modifications (DiGiuseppe, 1993).

Structure of the chapter

In describing an effective cognitive therapy approach to major depression, I will first define cognitive therapy, speak about the theory of cognitive therapy as applied to the problems of depression, focusing especially on conceptualisation, detail some techniques to use in assessing and treating depression, delineate steps in a typical course of treatment, and mention throughout common mistakes that even more experienced therapists may sometimes make in treating depressed clients. Finally I will offer suggestions throughout as to how to avoid many of these errors.

Defining cognitive therapy

Before beginning the discussion of cognitive therapy of depression, however, I want to emphasise that cognitive therapy is not a collection of useful techniques to be used in isolation. Indeed, Beck maintains that “cognitive therapy is best viewed as the application of the cognitive model of a particular disorder with the use of a variety of techniques designed to modify the dysfunctional beliefs and faulty information-processing characteristic of each disorder” (Beck, 1993, p. 194).

Cognitive conceptualisation of depression

According to Beck's cognitive specificity hypothesis (Beck et al., 1979) depressed clients have a different cognitive profile from those with other psychiatric problems, showing primarily themes of loss, defeat, and failure in their cognitive content. Their spontaneous verbal output typically reveals many examples of thinking (including metaphors and images) with a systematic negative bias. This is mirrored in clients' deeper, unspoken assumptions across many domains of their experience. Beck has especially called attention to the “negative cognitive triad” in depressed clients: a fairly unrelenting tendency to view themselves, the future, and their experience around them almost entirely in negative terms (Beck et al., 1979). Because of Beck's focus in the cognitive treatment of depression on identifying, evaluating, and modifying dysfunctional thoughts and deeper beliefs, some careless readers of his work are under the misapprehension that Beck assigns a causal role in depression to distorted thinking. When questioned, he has said that he would no more make that claim than to suggest that hallucinations and delusion cause schizophrenia (Beck et al., 1979). While Beck is careful to avoid saying with authority what exactly causes depression in the first place, since research itself has produced no definitive answers, he maintains that the mal-adaptive worldview of depressive clients helps to maintain most of the symptoms of depression as well as significantly interfering with their effective problem-solving of their many real-life problems (Beck et al., 1979). In many cases, indeed, clients' lack of effective action or their actually dysfunctional action flows from their maladaptive and overly rigid ways of viewing their situation. What cognitive therapy first seeks to do, therefore, is help clients to be more aware of their active ways of making meaning and to discover the adaptiveness or maladaptiveness of these constructions. This is called “decentering”, described by Safran and Segal (1990) as

a process through which one is able to step outside of one's immediate experience, thereby changing the very nature of that experience. This process allows for the introduction of a gap between the event and one's reaction to that event … Stepping outside of one's current experience fosters a recognition that the reality of the moment is not absolute, immutable, or unalterable, but rather something that is being constructed (p. 117).

Safran and Segal note, however, that mere theoretical awareness of this process is insufficient to induce necessary change: “For change to take place, however, patients must have more than an intellectual grasp of this notion. They must have the experience of actually seeing themselves construct reality” (p. 118).

After clients learn how to do this, their next task is to explore and learn to utilise other, more adaptive ways of understanding their own experience. As they practise this skill of disembedding from their dysfunctional constructions they become progressively better able to detect and resolve problems.

It is important for every clinician to develop and share with the client on some level his or her evolving cognitive conceptualisation of the client. The conceptualisation has two major parts. The first part is the general conceptualisation of the phenomenon of depression itself. This more generic idea of the typical characteristics, predisposing factors, as well as the likely cognitive, affective, behavioural and situational vulnerabilities helps the therapist better understand many of depression's common aspects. For example, the therapist can predict that a client will usually continue to feel bad if she spends a great deal of time oversleeping, avoiding most activity, and ruminating. The therapist can then educate the client about her own depression and what will tend to reduce or increase it. Educating the client in this way about the nature of depression can help her to break out of a sense of emotional helplessness (for example, “My moods just come over me and there's nothing I can do, Doctor.”). This can help to reduce demoralisation in the client and impart an increasing sense of self-efficacy in her (for example, “If I work to catch and reduce my all or nothing thinking, I'll feel better and enjoy things more” or “If I get up at 8 a.m. and plan my day with some forethought, I can feel satisfied during and at the end of the day”).

The second part is an individualized case formulation for each client to answer questions like the following: How does this particular client experience depression? What are the most salient features for her? What possible sociocultural effects might there be that could affect her experience of herself and depression? How do the symptoms all fit together? Which component tends to start the negative cycle? What mitigating factors in her depression can we utilise to help the client break free of her depression? So, although the above-mentioned similarities exist across many depressed clients, each client has a depression that is also unique. Historical factors and current situations as well as the personal construction of meanings will differ for each client. For this reason, the therapist must develop an evolving, multifactorial conceptualisation of each client. Most clients find it very interesting and gratifying to explore and collaborate on this. The positive effect, again, of such activity is often greater self-understanding and greater self-compassion. This can also lead to an enhanced sense of control and predictability over their moods, thoughts, and actions. There are several models for developing such an individualised case formulation. Beck (1995), for example, has a Cognitive Conceptualisation Diagram (1995, p. 139) that serves as a quick summary sheet of the most important information gathered over the early part of therapy. Layden (1997) also has developed a slightly more differentiated one that places increased emphasis on images as well as more positive beliefs and experiences of the client. Persons (1989, 1993) has written a full-length book and several chapters solely on the subject of conceptualisation. She has put forth a rather comprehensive model for understanding the major components of a client's problematic patterns. Whatever model the therapist uses, the basic conceptualisation probably needs to cover at least the following areas:

1 Major current problems (including behavioural, cognitive, affective, and physiological) the client is experiencing. For example, one might note that a client is depressed, sad, and nervous; tends to withdraw socially, drink alcohol every evening, and watch TV at home; tends to experience headaches and constant fatigue as well as a gnawing pain in her stomach; tends to blame herself for anything that goes wrong, tells herself that she really should pull herself up by her bootstraps and snap out of it, calls herself a loser and failure, and predicts continued misery and isolation for the rest of her life.

2 A few representative situations in which these problems occur with the unique behavioural, affective, cognitive, and physiological aspects noted. For example, a client becomes especially depressed and fatigued and withdraws from social contact whenever she receives criticism, even if well-intentioned. She then says to herself, “They must be right. I can't do anything right. It's just like my ex-husband used to say, I am a failure.”

3 Current predisposing events and situations. Example: mounting debt, death of a loved one, highly stressful job.

4 Any metaphors, similes, images, or dreams the client reports that represent important aspects of the problems under review. Example: a client's image of herself wrapped in chains in a cold, dark room and unable to move.

5 The current cognitive, affective, physiological, and behavioural strategies that seem to represent coping attempts (even if of questionable utility in the lon...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of figures and tables
• About the editor
• List of contributors
• Preface
• Introduction
• 1 The cognitive treatment of depression
• 2 Cognitive behavioural treatment of suicidal behaviour
• 3 Cognitive therapy of bipolar disorder
• 4 Cognitive behaviour therapy for panic disorder
• 5 Psychosocial treatment for OCD: Combining cognitive and behavioural treatments
• 6 Cognitive behavioural therapy for worry and generalised anxiety disorder
• 7 Cognitive behavioural treatment of eating disorders
• 8 Schema-focused therapy for personality disorders
• 9 Letting it go: Using cognitive therapy to treat borderline personality disorder
• 10 Techniques and strategies with couples and families
• 11 Cognitive behavioural therapy with children and adolescents
• Index