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 whether an intervention is labeled a "cognitive" intervention (vs. a behavioral or interpersonal intervention), that "provides a unifying theoretical framework within which the clinical techniques of other established, validated approaches may be properly incorporated" (Alford & Beck, 1997, p. 112). From this perspective, many different types of intervention that could be added to standard CT for depression might be useful in modifying maladaptive information processing.
Adapting standard CT for depression with supplemental interventions generally proceeds in one of two directions. First, a therapist might use additional clinical techniques in targeting other problems in a sequential fashion. For example, a clinician working with a patient who presents with comor-bid depression and a substance use disorder might first decide to treat the depression, then the substance use disorder, in a sequential fashion. In deciding upon the order of treatment, the clinician may want to begin with the problem that is most distressing to the patient. Another approach to sequencing of treatment strategies is to begin with the problem that is seen as primary (i.e., occurring prior to other problems) and subsequently moving to secondary problems once the primary problem is successfully treated. For example, if a patient has developed an addiction to a medication prescribed to help with insomnia he/she experiences as part of depression, it may be most useful to treat the depression first, then the substance use disorder. Alternatively, if marital conflict is seen as contributing to a patient's depression, it may be beneficial first to reduce the amount of conflict (e.g., reduce the frequency or intensity of criticism from a spouse) before targeting the patient's beliefs about the meaning of such conflict in CT for depression.
In comparison to sequential treatment, there may be occasions in which treatment interventions are provided simultaneously within a given session or across several sessions. For example, in a case in which depression and anxiety are equally distressing to the patient, targeting the two conditions might alternate from one session to the next. Thus, sessions focusing on CT interventions targeting symptoms of depression could be alternated with sessions focusing on CT interventions targeting symptoms of anxiety.
A third approach to supplementing standard CT for depression involves developing a treatment that specifically addresses a particular manifestation of depression. Thus, unlike a treatment that focuses on independent forms of intervention that are presented in a successive or alternating fashion, such a modification reflects the development of a different treatment protocol that is delivered for a particular manifestation of depression. For example, depressed individuals who are suicidal may be one example of a manifestation of depression that requires its own type of CT protocol. In this case, the treatment shares the theoretical underpinning of CT for depression, as well as some common interventions, but the resulting protocol may be different enough to be considered its own treatment.
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