The preceding treatment guidelines and clinical illustration highlight areas of importance when implementing CT with more severely depressed patients. Frequently, patients with severe depression require longer use of activity monitoring and scheduling than is the case for less severely depressed patients. This sustained focus on behavioral activation is important in increasing activities associated with positive mood generally, and with experiences of pleasure and mastery specifically. As indicated in our review, recent data suggest the promise of purely behavioral approaches to depression and underscore the importance of emphasizing such strategies within the CT approach. This recommendation is consistent with the seminal formulation of CT (Beck et al., 1979), as well as recent work emphasizing the importance of behavioral experiments in CT (Bennett-Levy et al., 2004). Special attention to the therapeutic relationship is also important. Particularly for patients with interpersonal stressors, it may be important to inquire regularly about whether patients experience the exploration of their beliefs and behavior as critical or judgmental. Finally, current evidence suggests that discussion of possible concurrent pharmacotherapy is advised. The guidelines reviewed here are intended to help maximize clinical competence, and ongoing formal monitoring of competence in CT is highly recommended to ensure that more severely depressed patients receive the most efficacious treatment possible.


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