Adapting the Emphasis or Focus of CT for Depression

Another direction for modifying CT for depression is to emphasize or to place a greater focus on one or more specific aspects of CT of depression. For example, Beck et al. (1979) hypothesized that greater severity of depression requires greater use of behavioral strategies in CT. Therefore, whereas behavioral interventions might be included in working with many depressed individuals, they may make up a larger percentage of sessions for people who are more severely depressed. Another area in CT...

Assessment Of Social Phobia And Panic Disorder In Depression

Social anxiety and social phobia can be assessed with behavioral observation methods (see for a review, Glass & Arnkoff, 1989) interview rating scales, such as the Liebowitz Social Anxiety Scale (LSAS) and the Brief Social Phobia Scale (BSPS Davidson et al., 1991 Liebowitz, 1987) and many self- report measures of social anxiety and avoidance, including the Fear of Negative Evaluation scale (FNE Watson & Friend, 1969) and the Social Avoidance and Distress Scale (SADS) by Watson and Friend...

Case Illustration

D., a 54-year-old African American woman identified as depressed by a nurse at her cardiac surgeon's office, reported low mood, crying, irritability, fatigue, poor concentration, disrupted sleep, and suicidal thoughts. At her initial visit, R. D. was diagnosed with major depression. She reported loss of interest for nearly 2 years and long-standing problems with low self-esteem. Most of her symptoms had been present for at least 2 months. Her Beck Depression Inventory (BDI) score was 28 and...

Marjan Ghahramanlou Holloway Gregory K Brown Aaron T Beck

Suicide is the 11th leading cause of death in the United States, with a rate of one completed suicide every 17 minutes (Hoyert, Kung, & Smith, 2005). Among individuals 15-24 years old, suicide is the third leading cause of death after accidents and homicide among individuals 25-44 years old, suicide is the fourth leading cause of death after accidents, malignant tumors, and heart disease (Hoyert et al., 2005). Approximately 20 of all U.S. suicides occur in elderly persons firearms account...

Group CT May Reduce Relapse and Recurrence

For example, Teasdale et al. (2000) randomized patients with recurrent MDD who were in recovery remission (i.e., who did not meet MDE criteria) for 12 or more weeks after discontinuing antidepressant medication, to treatment as usual (TAU i.e., patients sought help on their own, as needed) or to TAU plus mindfulness-based cognitive therapy (MBCT). CT included eight weekly group sessions followed by four monthly group sessions lasting 2 hours. Over 60 weeks, for 105 patients with a history of...

Medical Illness as a Target of Treatment

Other chapters have considered whether to treat comorbid conditions sequentially or concurrently. This is a clearly pivotal question for CT with patients who have multiple psychiatric conditions, but is it relevant to the treatment of comorbid depression in medical illness Depressed medical patients, too, can have multiple psychiatric and psychosocial problems (Bankier,Januzzi, & Littman, 2004). For example, if depression is the reason for referral of a patient with CHF, he she may also have...

Dysfunctional Attitudes and Beliefs

O'Leary et al. (1991) reported that patients with BPD, with or without major depression, scored higher than controls on a broad measure of dysfunctional attitudes. Cognitive theorists and therapists have described several specific beliefs and attitudes common among individuals with BPD. Beck et al. (1990), suggested that the individual views him herself as bad, unacceptable, and unlovable, which may be articulated in automatic thoughts such as I deserve to be hurt, I must be perfect, and I need...

Mechanisms For The Impact Of Bpd On Depression Outcomes

Why does BPD have such adverse impacts on outcomes of depression Shea, Widiger, and Klein (1992) discussed a number of possibilities, upon which we expand here. One is that depression with BPD may be biologically distinct. No good data directly support this position, although poorer outcomes for biological treatments, at least in uncontrolled studies, are consistent with it. A second possibility is that, compared to patients with depression only, there are differences in cognitive content and...

Assessment Of Chronic Depression

When therapists work with patients with chronic depression, the assessment process can be challenging on a number of fronts. Generally speaking, a patient comes to therapy with a long history of the disorder, and there is a lot of ground for the therapist to cover in terms of gathering sufficient information to make sense of current problems, sharing a treatment rationale with the patient, and devising an initial formulation of the development and maintenance of the disorder. A further...

Course of Treatment

Over the course of 20 A-CT sessions, Mr. Turner was taught the cognitive model. His forte was identifying and reevaluating logical errors in cognition, such as all-or-none thinking, overuse of should statements, perfectionism, and personalization. Because he was able to distance himself from his depression, he viewed himself as having a recurrent illness that could be treated rather than as weak and incompetent. The therapist used role plays and homework assignments to help Mr. Turner increase...

The Final Phase of Treatment

The cognitive model of depression assumes that individuals who become depressed generally have schemas or core beliefs that make them vulnerable to precipitating events (Young, Klosko, & Weishaar, 2003). More generally, according to the cognitive model, everyone has schemas that are the heritage of early experience, cultural and media messages, peer relationships, a history of mental health or disorder, and other developmental issues. Hypothetically, every person has his her own areas of...

Supplementing Standard CT

Supplements to standard CBT include an array of methods used in clinical child and adolescent psychology, as well as medications prescribed by child psychiatrists. Four commonly used psychosocial supplements include neo-behavioral techniques, school-based interventions, family-based interventions, and extended family or community interventions. Neobehavioral techniques are derived from more recent models of treatment, including dialectical behavior therapy (DBT), and mindfulness-and...

Kenneth E Freedland Robert M Carney Judith A Skala

Controlled treatment trials have shown that cognitive therapy (CT) is efficacious for a wide range of problems, but medically ill patients have been excluded from many of these studies. Consequently, less is known about CT for problems such as depression, stress, or anxiety in medically ill patients than in healthy individuals. This is starting to change as a number of research groups are testing cognitive-behavioral interventions for these problems in a variety of medical patient populations....

Outcomes

N. had marked decreases in self-injurious behaviors (overdosing, cutting, and hitting herself) moderate increases in attendance and timeliness for therapy and completion of self-monitoring forms moderate increases in work attendance, interpersonal assertiveness, and involvement in hobbies and moderate decreases in drug and alcohol use, self-blame and guilt, anger, and depressive symptoms. Progress across the year of treatment was far from linear, however. C. N. experienced several relapses...

CT for Residual Symptoms

After completing the assessment of the patient, including reading his her self-observation diary, the therapist formulates a cognitive package. This may encompass both exposure and cognitive restructuring. Exposure consists of homework exposure only. An exposure strategy is planned with the patient, based on the list of situations outlined in his her diary. The therapist writes an assignment per day in the diary, following an in vivo graded exposure (Marks, 1987). The patient is asked to rate...

Treatment Strategies for Each Class of Targets

Several strategies were implemented to address parasuicidal drug use. C. N. attended a DBT skills training group to learn to tolerate her intense guilt and rage. Problem-solving chain analyses like the one outlined earlier were used in individual therapy to identify points at which various coping skills could be employed. These were primarily from the Distress Tolerance and Emotion Regulation modules. For example, C. N. found that leaving the situation and engaging in intense exercise and...

Shared Psychopathology

According to Clark and Watson's (1991) tripartite theory, high negative affect is a common factor shared by both anxiety and depression, whereas low positive affect and high autonomic arousal are uniquely characteristic of depression and anxiety, respectively. Research testing the validity of the tripartite model in outpatients with anxiety and mood disorders has found that social phobia and depression are both distinguished by high negative affect and low positive affect, and that neither is...

Psychometric Measures

Although formal diagnosis is not a standard part of a CT assessment, diagnostic interview schedules such as the Structured Clinical Interview for DSM-IV (SCID Spitzer, Williams, Gibbon, & First, 1992) can provide a useful template to cover the main symptoms of depression. It is helpful to focus on a specific, recent time period (e.g., the last week), but the therapist should ascertain whether the chosen time period is reasonably representative of the patient's usual experience of depressive...

Comorbidity Of Depression And Anxiety

The National Comorbidity Survey (NCS) showed dramatically higher rates of panic disorder in individuals with a history of depression (Kessler et al., 1998). Chronologically, primary depression predicted the first onset of subsequent panic attacks but not of panic disorder. Chronologically, primary panic attacks, with or without panic disorder, predicted a first onset of subsequent major depression. Data from the NCS also indicate increased clini- cal severity when depression and panic disorder...

Treatment of Panic Disorder in Individuals with Depression

In a review of CBT for panic disorder, Mennin and Heimberg (2000) described the minimal impact of comorbid mood disorders, particularly at follow-up assessments. Dimensional studies of depressive symptoms at baseline do not reliably predict outcome of CBT treatment of panic disorder (Basoglu et al., 1994 Black, Wesner, Gabel, Bowers, & Monahan, 1994 Jansson, Ost, & Jerremalm, 1987). Likewise, categorical analysis of the presence or absence of comorbid major depression suggested similar...

Modifications in Timing Presentation and Implementation of Interventions

For complex childhood or adolescent depression, modifications of CBT often are needed. These are reflected in the case formulation, which may be modified as treatment progresses (Rogers, Reinecke, & Curry, 2005), as illustrated in three examples. Consider first the cognitively immature adolescent. Cognitive immaturity may be reflected in a lack of self-reflection or insight poor verbal abstraction skills an inability to identify and label emotions, and to appreciate relationships between...

Mechanisms For The Cooccurrence Of Mood Disorders And

Although a well-documented relationship exists between BPD and mood disorders, the exact nature of this relationship has been a subject of much speculation and controversy. Farmer and Nelson-Gray (1990) summarized eight hypotheses that have been advanced regarding relations between PDs and depression. Four of these (the orthogonal, overlapping symptoms, heterogeneity, and modification hypotheses) are primarily descriptive and do not propose a particular mechanism or suggest that no such...

Treatment Interventions and Outcome

Mary completed 14 cognitive-behavioral therapy sessions. In the first treatment session, the clinician provided feedback in a collaborative manner regarding the assessment and diagnostic findings. Mary agreed with the conceptualization, and she and her clinician discussed her goals for therapy. Mary reported that her main objective was to be less depressed. The clinician suggested that therapy begin with an increase in Mary's social involvements and pleasurable activities. A schedule of...

The Typical Course Of Therapy

Although the description of the process of CT sessions is important to learn and to use in treating depression, none of the processes I have discussed really address the content of the treatment of depression, or what I described earlier as the work phase of treatment. Unfortunately, there is no single cookbook or formula for treating depression. Every patient is unique and presents with his her particular history, past efforts to overcome depression, comorbid problems, schemas, and current...

Underlying Mechanisms

At the presumed root of a patient's overt difficulties lie the underlying psychological mechanisms, which represent the second level ofPersons's (1989) case formulation model. Indeed, an underlying psychological mechanism represents a problem or deficit that causes or contributes to an individual's overt difficulties. According to the cognitive theory of depression (Clark et al., 1999), maladaptive schemas are the underlying psychological mechanisms for depression and associated difficulties....

Individual Alone

The first option is to treat the individual alone, even if it is clear that family problems exist. This option might be chosen for pragmatic reasons (i.e., family members cannot or will not attend conjoint therapy). For example, even when a college student has conflict with his her family of origin, that family may not be local and may therefore not be available to participate in therapy. In other cases, case conceptualization may dictate the choice of seeing an individual alone. For example,...

Adaptation Of Standard Ct In The Treatment Of Depression In Medically Ill Patients

There are more similarities than differences between standard CT and cognitive-behavioral interventions for depressed medical patients. Some of the differences stem from the fact that many of these patients are referred by their physician, urged by their spouse to see a therapist, or recruited for participation in a clinical trial. Their demographic profile tends to differ from that of depressed but otherwise healthy patients who seek CT on their own initiative. Although some chronic illnesses...

Functional Assessment and Functional Analysis

Assessment is a longitudinal process. New data that come to light as patients go through therapy have implications for adjusting and updating the specific diagnoses, and for solidifying or revising the treatment plan. Early assessment often involves open-ended questioning about the patient's functioning in everyday life, specially noting areas of impairment. A comprehensive intake ideally involves the administration of the SCID (e.g., First et al., 1995), during which the patient's mood...

Other Medical Conditions

CT has been tested in other medically ill patient populations, with outcomes such as improved adjustment to illness, increased ability to cope with stress, and better health-related quality of life. Few studies have tested the efficacy of CT for comorbid depression in a defined medical illness. For example, the Lustman et al. (1998b) study described earlier is so far the only published trial of CT for depression in patients with diabetes. Most of the clinical trials published so far have been...

Conclusions

In this chapter we have presented a model for the assessment and case conceptualization of depression that focuses on different manifestations of depression. Specifically in assessing depressed patients, cognitive therapists are encouraged to consider depression parameters (e.g., severity, persistence), comorbid conditions (Axis I and II disorders, medical conditions, social functioning), and aspects associated with different demographic variables. Information gathered from this assessment can...

Description of the Cognitive Protocol

The cognitive protocol for treatment of suicidal behavior (Brown, Henriques, Ratto, & Beck, 2002) comprises one 60- to 90-minute psychoeducation session and approximately 10 (45- to 50-minute) weekly psychotherapy sessions. During the psychoeducation session, patients are informed that the offered treatment is short term and time limited. Patients are provided with a copy of Choosing to Live How to Defeat Suicide through Cognitive Therapy (Ellis & Newman, 1996). Treatment is initiated...

The Cognitive Theory Of Depression

CT rests on a theoretical model of human functioning that has been elaborated over the years. This model is based on a Realist epistemology (Dobson & Dozois, 2001 Held, 1995), which asserts that reality exists independent of human experience. At the same time, the model holds that humans are natural scientists and seek to make sense of the world and their experiences, through the development of broad, organizational cognitive constructs. The constructs were typically defined as core beliefs...

Treatment of Social Phobia in Individuals with Depression

Despite the high frequency and clinical severity of the co-occurrence of social phobia and major depression, many studies have excluded depression in clinical trials. For example, a meta-analysis of30 cognitive and or behavioral treatments of social phobia, published from 1996 to 2002, found that only 11 studies included patients with social phobia and comorbid depression (Lincoln & Rief, 2004). In this meta-analysis, the impact of comorbid depression could be examined only by comparing...

Review Of Efficacy Research

One of the strengths of CT is its strong empirical base, and this is well established in relation to acute depression. Much of the research evidence that addresses the effectiveness of CT on persistent symptoms comes from small-scale studies that have not been rigorously controlled. The earliest studies (e.g., Fennell & Teasdale, 1982) sounded a note of caution due to the low response rate. Response rates in subsequent studies (Harping, Letterman, Marks, Stern, & Johann, 1982 Gonzales,...

What Happens When There Is a Lapse vs a Relapse during CCT

It is important to teach patients to discriminate a full relapse (a syndrome with impairment that lasts 2 weeks or more) from a blip or lapse (transient symptoms that may resolve with intensified use of critical skills). Attention to the temporal aspects of the diagnosis and the effect of symptoms on functioning helps with this discrimination. Furthermore, it can be helpful to teach patients to use self-rating scales (e.g., BDI or IDS-SR) to detect depressive symptoms and to learn when to...

Integrating Overt Difficulties and Underlying Mechanisms

According to Persons's (1989) case formulation model, overt difficulties and underlying mechanisms are closely linked. Indeed, just as underlying negative beliefs may influence one's cognitions, behavior, and mood, overt difficulties may serve to reinforce one's underlying beliefs. Yet, in contrast to overt difficulties, which may be relatively accessible to patients and amenable to assessment by clinicians, it is more difficult to access and identify these underlying core beliefs. As such, it...

The Effect of Comorbidity on the Process and Outcome of Cognitive Therapy

Most of the literature regarding cognitive therapy (CT) of GAD, OCD, and PTSD describes treatments in which the disorders are considered in isolation. Most well-controlled, randomized clinical trials have focused on pure cases of anxiety or depression and have shown promising outcomes in the treatment of these conditions (Chambless & Ollendick, 2001). Yet the samples utilized in the empirically supported treatment literature include few (if any) participants who have comorbid depression and...

Modifying Standard CT for Depression and Comorbid Gad Ocd and PTSD

If the clinician determines that the depression should be treated first, we recommend that he she administer standard CT for depression, while remaining cognizant of the potential effects that the comorbid anxiety disorder may have on treatment. If the comorbid condition negatively impacts treatment progress, then the interventions may need to be modified. To treat comorbid depression, it is recommended that behavioral activation be emphasized, with the goals of decreasing depressed mood and...

Empirical Research On Depression With Lgb Women And

It is difficult to determine rates of depression in the LGB population, because definitions of sexual orientation are inconsistent and or unsophisticated in published reports. Many studies that define participants as lesbian or gay according to their self-reported sexual histories indicate higher rates of major depression (Cochran & Mays, 2000a, 2000b Gilman et al., 2001 Sandfort, de Graaf, & Schnabel, 2001) and other acute psychological disorders. However, use of sexual behavior as a...

Cognitive Therapy

Layden, Newman, Freeman, and Morse (1993) presented the first extended guide to conducting CT for BPD. Treatment is multifaceted, but focuses on helping patients to identify early maladaptive schemas, core unconditional beliefs about the self and the world, and the behavior patterns seen as driven by those schemas, and to work on changing the schemas. Layden et al. suggest that of 15 early maladaptive schemas (EMSs) identified by Young (1990), those most commonly present in BPD are...

Conceptualization Of Chronic Depression

Chronic depression is not a homogenous problem, and patient history, course of current episode, and presentation can vary widely. As in the standard CT model for acute depression (Beck, Rush, Shaw, & Emery, 1979), the theme of loss (actual and perceived) and the negative cognitive triad (negative view of self, world, and future) are helpful as an initial starting point for formulating the patient's problems. However, in the model of chronic depression, the losses are often more enduring and...

Specific Clinical Features Of Depression Associated With

Gunderson and Elliott (1985) reviewed early studies that suggest depression in BPD is characterized by loneliness, emptiness, boredom, and feelings of worthlessness and hopelessness, rather than guilt, remorse, and low self-esteem. Suicidal ideation and overt suicidal behaviors are more common among depressed patients who also have Cluster B personality disorders (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987), and McGlashan (1987) reported that depressed patients with BPD were more...

CT with African Americans

Ethnic awareness requires the recognition of potentially large differences in values and experiences between patient and clinician. Interdependence, spirituality, and discrimination are consistently cited markers of cultural difference between mainstream and ethnic minority populations (Hall, 2001). Despite mounting evidence of the importance of cultural competence in working with ethnically diverse patients, clinicians often make the mistake of overlooking or misunderstanding these constructs...

The Central Role of Evaluation and FollowUp in Relapse Prevention Prerequisites to Learning and to Providing CCT

A therapist with a firm foundation in cognitive theory and diagnostic and behavioral assessment has the background to learn to provide C-CT to promote remission and recovery, and to reduce relapse. Cognitive theory guides therapists in identifying patients' emotional vulnerabilities, and learning theory guides them in teaching patients new behaviors to cope with the inherent vulnerabilities of suffering from a recurrent, often chronic illness, to cope with coming to painful conclusions about...

Cognitive Therapy For Depression In Patients With Comorbid Pds

Once some of the symptoms of depression have been relieved, the therapeutic focus switches to core schemas about self and life, which tend to trigger problems and depressive symptoms (Young, Weinberger, & Beck, 2001). Educating the patient about schemas is pertinent in this phase, for instance, explaining that schemas are rules by which people live and how they make sense of the world. Next, it is important for the patient reflectively to explore and identify personal schemas. Through the...

Case Conceptualization

N. reported that in 1 year during middle childhood, her father died and a family member sexually abused her. She felt blamed by her family for encouraging the rape. Reactions to the sudden loss of her father were not processed, and she was not permitted to mention him ever again. She reported a lifelong history of both physical and emotional abuse from her mother and a family that often referred to her as crazy and ill due to her frequent emotional outbursts. She also reported several...

Impact of Family Problems on Cognitive Therapy for Depression

Although one might speculate that the presence of serious family problems decreases the efficacy of cognitive therapy (CT) for depression, there is actually very little research on this topic. Individuals in CT who reported that relationship problems were a cause of their depression (relative to those who did not) were less likely to complete homework and showed a poorer response to treatment (Addis & Jacobson, 1996). Beach and O'Leary (1992) also found that depressed married women with...

Initial Assessment Case Conceptualization And Treatment Planning

With the trend toward manualization of psychosocial interventions, there have been increased attempts to clarify a distinction between the essence of a treatment and its specific components (Abramowitz, 2006) that is, along with certain techniques that make up an intervention, it is important that there exist an empirically based theoretical rationale to guide the treatment. This approach is at the heart of evidence-based practice generally, and of cognitive therapy (CT Beck, Rush, Shaw, &...

Late Phase of Treatment Sessions 810

Formal assessment of how well the patient has learned cognitive-behavioral skills is warranted at the final stage of treatment and is accomplished by the patient's completion of a guided imagery exercise, the relapse prevention task (RPT). The purpose of the RPT is twofold. The first aim is to activate images, thoughts, and feelings associated with previous, or the most recent, suicidal behavior in a safe therapeutic environment. The second aim is to evaluate treatment progress by directly...

Treatment Of Depression Among Adolescents Adaptations of Standard Cognitive Therapy

Three CBT protocols have been developed for use with depressed adolescents. The first of these is based on the standard model of cognitive therapy (CT) for depression developed by Aaron Beck and his colleagues (Beck, Rush, Shaw, & Emery, 1979). Based upon cognitive diathesis-stress paradigms, this model emphasizes the importance of changing automatic thoughts, maladaptive tacit beliefs or schemas, and other cognitive products or processes associated with depression as a means of bringing...

Augmenting Standard CT for Depression

A final method for adapting CT for depression is to supplement standard treatment with additional treatment interventions. From a theoretical perspective, interventions that are compatible with the cognitive theory of depression (i.e., the theory that maladaptive information processing is central to understanding the onset, course, and treatment of depression Clark et al., 1999) can be appropriately considered to be cognitive in nature that is, it is compatibility with cognitive theory, and not...

Sharing the Case Formulation with the Patient

Practitioners of all forms of CBT share with the patient, typically during the first few sessions, their conceptualization of his her difficulties. With BPD, some clinicians may be reluctant to discuss the diagnosis or case conceptualization, because patients quickly learn that many clinicians view this diagnosis negatively and resist accepting the label. However, we believe that this knowledge is important insofar as there is somewhat effective treatment, and that the diagnosis can be...

Individualizing the Multifactorial Model of Risk and Prevention

Therapists use the results of the diagnostic and behavioral assessment to personalize the model of risk and prevention (described earlier) for each patient. Patient and therapist collaboratively address the following questions (1) What risk factors have been involved in the initial and recurrent pattern of the patient's depression, and (2) which compensatory skills, and changes in behavior and outlook, have been associated with a decrease in depressive symptoms and improved functioning and life...

Cognitive Therapy For Depression

Cognitive therapy (CT) was first named and identified as a distinct type of treatment in an article in 1970 (Beck, 1970), in which Aaron Beck described CT, and distinguished it from behavior therapy, based on the increased attention paid to negative thinking in CT and the importance of core negative beliefs, also seen to be pivotal in the genesis of depression. In the mid-1970s, Beck and colleagues engaged in the first trial of this new form of treatment for depression (Rush, Beck, Kovacs, &...

Conceptualization Of Comorbidity Of Family Problems

For depressed individuals who are experiencing family difficulties, the cognitive therapist may develop an integrative case conceptualization that takes into account family and interpersonal issues, as well as individual cognitions, emotions, and behaviors. A few points about conceptualizations bear mentioning here. As Jacobson and Christensen (1996b) point out, a conceptualization (or formulation) is not a static concept rather, it evolves and changes over time as new information is...

Cluster B

Patients with Cluster B disorders have as their major shared style a pattern of high arousal. When their arousal needs are not met, they often become frustrated, angry, and disappointed, which then manifest as depression or depressive-like symptoms. We may term this depressive reaction as deprivation depression. When they have their arousal needs met, they do not experience the same disappointment and subsequent depressive reaction. An alternative reaction is the more commonly described...

The Middle Phase of Treatment

Once the patient is more active and involved in his her environment, the focus of therapy quickly shifts to cognitive assessment and restructuring. The term cognitive restructuring refers to a large number of interventions that generally focus on situation-specific (as opposed to underlying, broad, or trait-like) negative thinking. As noted earlier, depressed patients can perceive the world accurately or in a distorted fashion (Beck et al., 1979 J. S. Beck, 1995 Clark et al., 1999), and the...

Assessment Of Comorbidity Of Gad Ocd And Ptsd

Due to the high rate of current co-occurrence between depression and anxiety, it is always important for the clinician to inquire about anxiety disorders when interviewing patients who present for treatment of depression. However, the need to inquire is accentuated when soft signs are present. For example, a patient with a history of abuse would prompt a clinician to inquire about PTSD. A history of unreasonable fears, such as those related to contamination, would indicate the need to screen...

Frequency and Continuity of Sessions

Maintenance of continuity and consistency across sessions is also particularly important when treating more severe depression. Typical research protocols with such patients have specified the use of twice-weekly sessions for the first half of a 4-month protocol (DeRubeis et al., 2005 Dimidjian et al., 2006). Frequent sessions early in the course of treatment can maximize patient engagement with treatment and ensure success with initial homework assignments. In addition, such frequency helps the...

Objective 3 Developing a Cognitive Case Conceptualization for Suicide Behavior

The cognitive case conceptualization is an individualized cognitive map of the current automatic thoughts, conditional assumptions, and core beliefs activated before, during, and after suicidal behavior. It is based on collected data about the patient's early childhood experiences, typical activating events, associated automatic thoughts, emotional responses, and subsequent behavior. Figure 7.2 illustrates a completed cognitive case conceptualization diagram for a depressed suicide attempter....

Attention and Focus Redirection

Decreased attentional resources, particularly selective attention, or the ability to tune out distracting or extraneous stimuli, also present a challenge (McDowd & Birren, 1990). In particular, older patients' ability to focus on discussions in therapy, to conduct structured tasks, and to answer directive questions is affected by their ability to concentrate on the task at hand. Deficits in attention and focus look very much like tangential thinking in the therapy context. As an example, one...

Brief Problem Solving and Goal Setting

A fourth option is to assist the family with problem solving or goal setting which can be accomplished in the context of a few family meetings. This may be appropriate for some circumscribed family problems, or if the therapist believes that a few, relatively small behavior changes might make a big difference to the depressed individual or to his her family. For example, a depressed patient who believes I must take care of everything in the house or else it won't get done may take on a lot...

Diagramming The Cognitive Case Conceptualization And Presenting It To The Patient

Cognitive Conceptualization Diagram

To aid in the development of the cognitive case conceptualization, it may be useful for clinicians to diagram the conceptualization. Such a diagram can be useful in organizing the information available about the patient. J. S. Beck (1995) provided a Cognitive Conceptualization Diagram that we believe is particularly useful in mapping information about the patient. This diagram includes spaces for depicting the relationship between automatic thoughts, and emotional and behavioral reactions, as...

Psychoeducation and the Early Phases of CT with Older Adults

The initial phases of CT typically focus on first ascertaining the patient's reasons for seeking treatment, his her experience with therapy and expectations, then socializing the patient to CT. Older adults in particular may need considerable education about the expectations of therapy, as well as the structure of CT. Often, older adults' attitudes about their own age group can interfere with effective treatment (Knight, 2004 Laidlaw et al., 2003). Older people often have little exposure to...

Giovanni A Fava Stefania Fabbri

There is increasing awareness that the majority of depressed patients fails to respond to an appropriate trial of antidepressant drug of adequate dose and duration (less then 25 symptom reduction from baseline) or shows a partial response (25-49 symptom reduction from baseline), or achieves a response without remission (50 or greater symptom reduction from baseline but presence of residual symptomatology) (Fava, 2003). Several pharmacological strategies have been developed for depressed...

Laura Kohn Wood Glenetta Hudson Erin T Graham

The Surgeon General's report on mental health (U.S. Department of Health and Human Services, 1999) detailed the efficacy of available treatments for mental disorders in the United States. Cognitive therapy (CT) and cognitive-behavioral therapy (CBT) approaches to the treatment of major mood and anxiety disorders show particularly favorable outcomes in comparison to other psychotherapy and psychopharmacological interventions (for review see the Special Section of the Journal of Consulting and...

McMaster Structured Interview for Family Functioning

The McMaster Structured Interview for Family Functioning (McSIFF Bishop, Epstein, Keitner, Miller, & Zlotnick, 1980) is a 90-minute structured interview designed to assess the areas of family functioning in the McMaster model. Clinicians may choose to use this interview (or parts of it) to make sure that they are conducting a comprehensive assessment of family functioning. For example, the interview includes a broad list of family responsibilities (e.g., housecleaning, shopping, preparing...

Conceptualization Of Depression In Older Adults

Late Life Depression Elderly

Z is a 75-year-old, widowed man who suffers from macular degeneration and diabetes, which resulted in above-the-knee amputation. He lives on the second floor of a walk-up building and has difficulty leaving his apartment because of his poor eyesight, and because his prosthesis no longer fits his leg since Mr. Z's weight loss of 15 pounds in the past year. His only income is social security, with which he barely makes ends meet. Since his eyesight began to fail and his disability increased,...

Stages of Learning Acquisition Generalization and Maintenance of New Skills

C-CT draws liberally from learning theory and emphasizes strategies to promote acquiring, generalizing, and maintaining new responses (Ferster, 1973). Social learning theory (e.g., Bandura, 1977) emphasizes the impor- TABLE 6.1. Sample Compensatory Skills Learned during Cognitive Therapy Restructuring via hypothesis testing Understands that thoughts, feelings, and behaviors can contribute to depression. Notices how view of self, world, and future influences behavior. Recognizes and records...

Robin B Jarrett Jeffrey R Vittengl Lee Anna Clark

Relapse and recurrence prevention are essential to improving treatments for depressed individuals. In this chapter, we describe how to reduce the likelihood of relapse by using continuation-phase cognitive therapy (C-CT) for adults with recurrent major depressive disorder (Jarrett, 1989 Jarrett & Kraft, 1997), and we present an overview of the conceptual and empirical foundations of C-CT. We show why many patients may benefit from C-CT how to begin implementing this treatment to reduce...

Special Considerations

Clearly, this chapter points to the prevalence of depression among patients with PDs. It is evident the depression is very pervasive among most patients with PDs, causing difficulty in accurate diagnoses and subsequent treatment planning. The modification of standard CT provides an example of overcoming the complications of depression with comorbid conditions. Perhaps another approach is to examine depression as a separate issue, out of the mood disorder category and into the personality...

Brief Ongoing Assessment of Suicide

Following a comprehensive evaluation, the clinician conducts brief ongoing assessments of suicide risk to monitor changes in the patient's overall status. Knowledge about established risk factors helps the clinician make informed judgments about potential risk. Table 7.1 provides a summary of several of these risk factors that are initially assessed during the comprehensive evaluation and subsequently monitored closely during the course of treatment. During the therapy process, the clinician...

Middle Phase of Treatment Sessions

The therapeutic work completed during the middle phase of treatment is grounded in the generated cognitive conceptualization. The primary focus is on helping the patient to develop adaptive cognitive and behavioral skills to better manage future suicidal behavior. Objective 1 Modifying Negative Suicide-Relevant Automatic Thoughts and Core Beliefs Once the patient's automatic thoughts and core beliefs in relation to his her suicidal behavior are identified, the therapist first assists the...

Selecting Measurements Whats Available

At intake, differential diagnosis of MDD is necessary to identify appropriate alternative acute-phase treatment options, and throughout A-CT, symptom assessment is key in structuring therapy sessions, gauging acute-phase treat- ment response, and identifying which patients need C-CT. Instruments that clinicians may use to measure the syndrome and severity of depressive symptoms are described below. To assess the syndrome of depression, to rule out other disorders, and to diagnose concurrent...

Conceptualization Of Depression And Treatment For Ethnic Minorities

We often think that major depression and other disorders look the same for all groups of people however, several researchers have questioned the assumption of universality with regard to psychological distress and symptomatology (Johnson, Danko, Andrade, & Markoff, 1997), arguing that universal diagnostic criteria cannot adequately capture cultural or race-based aspects of emotional distress (Trierweiler & Stricker, 1998). Efforts to enhance the cultural validity of DSM-IV resulted in the...

DBTs Biosocial Theory of BPD

DBT organizes the nine DSM-IV criteria for BPD into five broad areas of dysregulation that clarify what skills the patient needs to learn and practice (Linehan, 1993a). These are (1) emotion dysregulation (labile affect and undercontrol overexpression of anger), (2) relationship dysregulation (stormy, chaotic relationships and fears of abandonment), (3) self-dys-regulation (lack of sense of identity, emptiness), (4) behavior dysregulation (suicidal and self-injurious behaviors, and other...

Mechanisms of Change and Predictors of Outcome in CT for Depression

Given the success of CT for depression, a number of ancillary questions arise, including questions related to how CT exerts its influence and whether the treatment is more or less appropriate for clients with known characteristics. The first of these questions was examined by mediational analyses and the examination of therapy processes related to outcome. Results of these studies include the observation that early completion of homework is associated with better clinical outcome (Startup &...

Approaches To Treatment

There are many options for integrating family interventions into individually based CT for depression. The integrative case conceptualization, as well as pragmatics, guides the choice of family intervention level and the specific strategies used. Options include (1) treating an individual alone (2) including family members in a few sessions for the purpose of assessment (3) providing psychoeducation to family members (4) brief problem solving with family members (5) including a family member as...

The Goal Of

The goal of C-CT is to teach, generalize, and maintain critical skills that prevent relapse and promote remission and recovery (Jarrett & Kraft, 1997). In short, cognitive therapists not only treat depressive symptoms but also teach new coping strategies. As in A-CT, therapists work to decrease, eliminate, and prevent the symptoms and syndrome of depression by teaching patients compensatory skills that include (1) understanding relations between cognition and other behavior, (2)...

Cluster C

Patients diagnosed with any of the Cluster C PDs have the best outcomes for therapy, particularly when compared to individuals with Cluster A or Cluster B disorders (Magnavita, 1997). Typically, patients with Cluster C disorders experience high levels of anxiety and fear, and have difficulty expressing emotions. Based upon this premise, patients in this cluster experience more impairment as they seek treatment services to fix Axis I disorders, such as depression and anxiety therefore, patients...

Adaptation of Standard CT for Depression

Given the invalidating climate in which LGB individuals typically are raised, it is imperative when working with this population that therapists not assume that all negative thinking is indicative of a cognitive distortion. Perhaps this is the greatest adaptation one needs to make when working with LGB patients. While attesting to the fact that lesbian and bisexual women generally have the same types of problems as nongay women, Wolfe (1992) suggested that irrational beliefs about need for the...

Assessment Of Depression For Ethnic Minorities

Although several instruments for assessing depressive symptoms and major depression exist, some measures may not adequately or appropriately include symptom patterns or idioms that characterize the illness for ethnic minority patients. Improved understanding of possible racial or ethnic variations in the manifestation of depressive symptoms will increase diagnostic accuracy (Ayalon & Young, 2003) and lead to better characterization and detection of disorders across distinct groups....

Objective 1 Engaging the Patient in Treatment

Depressed individuals with suicidal behavior may present for treatment due to pressure placed upon them by family members or friends, or they may at times appear apathetic, uninterested, or even hopeless about the therapeutic process. The general clinical recommendations we provided earlier have already emphasized the importance of therapy attendance and compliance, implementing a psychoeducation component, a team approach to intervention, and the role of sociocultural factors in treatment...

Assessment Of Depression With Lgb Women And

Patient verbal self-report and written self-report measures are standard in clinical practice. Although standard self-report measures are useful, clinicians need to review their customary forms for heterosexist content. For example some questionnaires ask about social anxiety around people of the opposite sex. The assumption is that heterosocial anxiety will complicate the individual's establishing intimate relationships. However, simply rephrasing the question to ask whether the patient...

Case Conceptualization Of Comorbidity Of Gad Ocd And Ptsd

The case conceptualization of comorbidity is crucial in treatment. The approach described in this section is adapted from Persons and Davidson 2001 . The case formulation needs to be modified to account for comorbidity between depression and GAD, OCD, or PTSD. For the patient with comorbidity, the problem list likely includes difficulties related to both depression and the anxiety disorder. Some of these problems may result from the depression, the anxiety, or both disorders. The patient's...

Drug Tapering and Discontinuation

Sequential treatment offers a unique opportunity for antidepressant drug tapering and discontinuation. In fact, it offers the opportunity to monitor the patient in one of the most delicate aspects of treatment. In the original studies Fava et al., 1994, 1998 antidepressant drugs, mainly tricyclics, were decreased at the rate of 25 mg of amitriptyline or its equivalent every other week. When selective serotonin reuptake inhibitors SSRIs are involved, more gradual tapering is the better. It is...