Adaptations to Standard CT When Working with Chronic Depression

Many aspects of how chronically depressed patients present indicate that unless there is active management of a structured process, therapy can disintegrate into a diffuse entity that lacks focus and direction. This can lead to hopelessness and despondence in both patient and therapist. It is in this area that, if the therapist can accept the idea that "everything is grist for the mill" and not become exasperated at him/herself or the patient, therapy can be its most productive and rewarding.

Separating the patient from the depression can be very liberating in terms of increasing the therapist's level of empathy, care, and motivation toward the patient. The cognitive deficits that characterize chronic depression include poor recall, poor problem-solving skills, over general autobiographical memory, and rumination. All of these have a real and vivid impact in terms of how the patient functions in the session and go a long way to account for the paralyzing negativity, passivity, and seeming intransigence that manifests itself during treatment sessions. It is all too easy when confronted with a chronically depressed patient to attribute these factors to personality. We encourage the therapist to be mindful in considering what part of the patient's presentation is personality and what part of the patient's depression and the very real cognitive deficits that result from it. How the therapist attributes these factors impacts the level of hope the therapist is likely to bring to the therapy.

The Therapeutic Relationship

CT is predicated on the ability of the therapist and patient being able to establish a sound therapeutic relationship. However, patients with chronic depression can present considerable obstacles to conveying the warmth, genuineness, and empathy that are considered the foundation stones ofthe therapeutic alliance.

Given that cognitive, emotional, and behavioral avoidance are so central in chronic depression, many patients react to the therapist's display of warmth and empathy in an aloof or hostile manner. The patient's beliefs about him/herself and others also influence his/her interactions with the therapist. A patient may find it hard to accept expressions of warmth and care and may greet them with suspicion and distrust. A highly autonomous patient, or one who sees emotionality as weakness, may interpret signs of care and concern as confirmation of his/her own perceived inadequacy and become more hopeless and passive, as well as hostile toward the therapist. These processes are best managed by adopting the therapeutic stance that takes into consideration the impact of the patient's belief system has on the therapist's interpersonal style.

Session Structure

The "style of therapy" refers to the role the therapist takes in shaping the nature of the interaction with the patient. In chronic depression, structure is vital. The hallmark of CT is its proactive, goal-orientated intervention in which the therapist is active and collaborative and uses primarily a questioning format to facilitate guided discovery. There are several ways in which different facets of chronic depression impact on therapy style. These include passivity in behavior and social interaction, rigidity of thinking, and avoidance of emotion. The style of therapy thus needs to be adapted in order to gain a balance between the activity level of the patient and that of the therapist as well as to maximize the chances of cognitive and behavioral change and evoke emotion within the session. Using standard CT interventions is painstaking and their implementation requires a good deal of patience and persistence on both sides before yielding results. This can be frustrating for both patient and therapist. Being explicit about this and articulating the nature of the ballpark the therapy is occupying can be beneficial in terms of establishing expectations that it usual for progress to be slow but systematic.

As a guiding principle, each session needs to be structured and action orientated with a clear goal in mind. Ideally the aim of both patient and therapist is to tackle a problem actively in session and generate a homework assignment that builds on that session's work.

Homework

Homework is a central mechanism of change in CT (Burns & Spangle, 2000; Garland & Scott, 2000), and there is some evidence that the extent to which patients engage in homework predicts outcome in CT (Kazantzis, Dean, & Roman, 2000). In chronically depressed patients, a number of factors are likely to interfere with the completion of homework assignments. Behavioral and cognitive avoidance work directly against the patient's engagement with any task that has the potential to require effort or to generate distress or negative automatic thoughts. Emotional avoidance and suppression can lead to the patient's passivity and result in a deficit in the moti vation to execute new tasks. The following strategies maximize the likelihood of the patient engaging in homework assignments:

• Establish assigning and reviewing homework as a routine part of the structure of each session.

• Establish homework assignments collaboratively to increase patient ownership of the works.

• Use the work of the session to generate homework tasks and assign these as the session progresses rather than at the end.

• Make the task realistic and achievable from the patient's perspective and set a maximum of two tasks.

• When asking the patient to monitor or modify automatic thoughts, ask him/her to work with a maximum of two examples. This minimizes the chance that the task will feel overwhelming to the patient.

• Be clear regarding what the task is, and use a written plan, with the audiotape to support it.

• Anticipate obstacles to non completion and try and minimize their impact by having alternate plans.

• Always review homework and reinforce verbally and in a written summary what the patient has learned, even when (which is the most common scenario) it has not gone according to plan.

Questioning Style

Given the level of passivity in chronic depression, the therapist is left with no option in the early stages of therapy other than to be more active than usual. Because there is a danger that such a stance will reinforce patients' passivity and lack of engagement, the therapist maintains a questioning style. However, one of the greatest challenges in chronic depression is that patients often respond to the therapist's questions with caution, anxiety, or even hostility. This response may be governed by a number of factors. For example patients who have high standards and perceive themselves as failures may become anxious in the face of questions. They may experience automatic thoughts about appearing stupid, not knowing the answer, and failing. Other, more interpersonally sensitive patients may experience the questioning style as undermining and perceive that the therapist is trying to catch them out in some way. It is therefore par for the course that standard CT techniques are likely to trigger patients' conditional and unconditional beliefs. The therapist needs to articulate and formulate these concerns with the patient to manage them effectively.

Experience tells us that when introducing interventions, therapists need to explain them carefully and provide written guidelines. It is also helpful to prepare the patient for how he/she might react to the intervention and seek permission to proceed. Furthermore, once the patient's foibles are known, the therapist can preempt possible activation of beliefs with statements such as "I need to ask a difficult question that may be upsetting, but if you can consider it, we may be able to understand the problem more clearly." This often gives the patient sufficient time to approach the question and to have a sense of control within the interaction. It also may help to create a path toward a productive dialogue about how a patient's perceptions about him-/ herself and others influence everything he/she does, including therapy. This is often a very useful lever for promoting effective change. However, it is difficult to convey in text the style of this kind of therapy. It is frequently painstakingly slow, often with silences and long pauses, and requires a lot of proactive engagement from the therapist to see an intervention to the end. A reasonable summary would be that it is more akin to taking the long and winding road than to taking the route the crow flies.

Regulating Affect

Given the different kinds of avoidance described in the chronic depression model, the therapist has to adapt the style of therapy to regulate the intensity of affect in the session. In therapy for patients with acute depression, therapist regulation of the intensity of emotion occurs through engagement in different tasks of therapy. Thus, the distress evoked by focusing on problems or painful thoughts and feelings can be ameliorated by identifying coping strategies. In chronic depression, inappropriate levels of affect can interfere with many of the tasks of therapy. This interference may result from the suppression of affect or from the overwhelmingly high levels of emotion that result when cognitive and emotional avoidance break down.

When there is insufficient emotional arousal, it is difficult to identify problems, and any negative automatic thoughts that are elicited possess little emotional immediacy or resonance: They are "cold" rather than "hot" thoughts. Attempts at questioning these "cold" thoughts are more likely to lead to rationalization or rumination than to genuine evaluation. Thus, the therapist needs to gear therapy in a way that provokes a degree of affect, and this is achieved by playing dumb and adopting an inquisitive style. In doing so, the therapist creates the impression that he/she makes no assumptions about what the patient is doing, thinking, or feeling. This puts the onus on the patient to go into detail to inform the therapist. Using this method over time, the patient gradually increases the emotional relevance of the discussion and subtle signs of emotional arousal, such as fidgeting or increase in speed of speech, may occur. This opens the way for the therapist to use standard interventions to optimum effectiveness.

In contrast, with patients who have little control over seemingly overwhelming emotional reactions, the use of standard interventions may be experienced as aversive, and the therapist can feel like he/she is walking on eggshells. A useful tactic here is for the therapist to be a step ahead of the patient, to guide him/her over what might seem to the patient like rugged and dangerous terrain. In working to contain excessive emotion, the therapist needs to be directive rather than to probe. When a patient is clearly struggling to contain strong emotion, asking more questions may further escalate the intensity of emotion, leading the patient to feel very out of control. This can be experienced by the patient as potentially catastrophic. To maintain collaboration, the therapist needs to indicate that although the patient feels very out of control, some control remains in the therapeutic situation. The therapist can facilitate a degree of control over the emotional intensity in the session by offering an explanation for the patient's emotional state (e.g., activation of a core conditional or unconditional belief), and suggesting and trying out ways of dealing with it and managing it in the session. It is also useful, as discussed previously, to help the patient anticipate an increase in distress by warning him/her that this is likely to occur and is indeed necessary to promote change. The therapist can explain how these emotions in a therapy session can be experienced more safely than in the outside world, with less likelihood of additional ramifications based on the patient's reactions. This is tempered as the therapist overtly displays in both verbal and nonverbal communication a level of confidence that he/she can and will guide the patient through this painful process in a way that is beneficial.

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