Adapting the Style of Presentation of CT for Depression

Another potential way to modify treatment concerns the style or manner of conducting CT; that is, there may be individual differences in preference and responsiveness to different types of CT interventions. For example, the underlying personality characteristics of sociotropy and autonomy are believed to be associated with how depressed individuals respond to different aspects of treatment. This has been labeled the differential treatment hypothesis (Clark et al., 1999). According to Beck (1983), patients who are high in sociotropy prefer and are more responsive to interventions that emphasize support, helping, and emotional closeness. It is hypothesized that these individuals likely prefer an informal and closer relationship with their therapist and may rely on him/her to help them solve their problems. In comparison, patients who are high in autonomy prefer and are more responsive to goal-directed, task-focused, and problem-oriented interventions. It is hypothesized that these individuals likely prefer a more formal, detached relationship with their therapist, and respond to a collaborative relationship in setting the agenda, selecting topics for each session, and assigning homework.

To be able to adapt CT in response to the differential treatment hypothesis, clinicians need to administer a measure of sociotropy and autonomy. To aid in interpretation of such measures, we have provided normative data on two of the most commonly used measures of these constructs—the Revised Sociotropy-Autonomy Scale (SAS; Clark & Beck, 1991) and the Revised Personal Style Inventory (PSI-II; Robins et al., 1994). To obtain normative data on these measures, we used PsycINFO to identify articles that cited the original reference for the measure, then, similar to the methodology used by Dozois et al. (2003), included data from studies that were written in English and based on the original standardized format of the measure, that involved samples not based on cutoff scores, and that excluded people with serious physical or mental health problems. The resulting means and standard deviations for this scale are provided in Table 2.1.

As with the data on cognitive measures, normative data can be used to compute T-scores that evaluate a patient's relative elevations on sociotropy versus autonomy, which in turn provides information used to modify treatment to match the person's dominant (i.e., highest scoring) personality style. For example, raw scores of 110 on the Sociotropy and Autonomy scales of the PSI-II, although equal at the level of raw scores, translate into a T-score of 60 on sociotropy:

T = 50 + 10[(110 - 95)/16] = 50 + 10(1) = 50 + 10 = 60

and a T-score of 70 on autonomy:

T = 50 + 10[(110 - 84)/14] = 50 + 10(2) = 50 + 20 = 70

Because the T-score is higher (by a full standard deviation) for autonomy than for sociotropy, a patient with these scores might be expected to benefit from problem-oriented interventions and actively collaborate with the therapist in structuring therapy.

Research on the differential treatment hypothesis has focused on whether sociotropy and autonomy are associated with differential treatment response to pharmacotherapy or group versus individual CT (Clark et al., 1999). As such, there is little empirical evidence to indicate whether tailoring treatment focus and therapist style based on a patient's level of sociotropy or autonomy is associated with a patient's preference and response to CT for depression, although this would be an important and clinically informative area for future research.

In addition to modifying the therapist's style and mode of interacting with patients, another aspect of CT for depression that may be modified is the way the treatment is presented to patients. For example, it may be important to change the cognitive rationale provided to certain types of patients. Along these lines, it has been suggested that a cognitive rationale focusing on negative aspects of self-appraisal is inappropriate for older persons experiencing a first episode of late-onset depression, because it does not adequately address the functional roles that positive beliefs have had in maintaining self-esteem over a lifetime (James, Kendell, & Katharina, 1999).

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