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 his assertive behavior and respond effectively when choir members criticized him. He also learned to prioritize and schedule his major responsibilities, to have time for himself and his family.

When he began therapy, Mr. Turner was uncertain about his value as a choir director, so he was ambivalent about his occupation. The therapist hypothesized that this stemmed in part from the anxiety and dissatisfaction with being a choir director as a result of his excessively high standards. As he was able to lower his unrealistic expectations, Mr. Turner came to experience being a choir director as a choice rather than an obligation.

When Mr. Turner began C-CT after completing the 20 A-CT sessions, he had been depression-free for 9 weeks. During C-CT, he continued working on the way he viewed himself. He came to see his depression as a medical disorder rather than a sign of weakness and to change his belief that "people with a strong faith don't ask for help." He also continued to reevaluate how he interpreted his mood shifts. Mr. Turner came to view shifts in his mood as triggers to use the skills he had acquired in A-CT, rather than as signs of inevitable depression. Furthermore, he applied the social skills he had acquired to speaking with religious colleagues, parishioners, and family about his stressors and pressures, and asked for their help. He even began to encourage others to seek help for problems they experienced.

During the fourth session of C-CT, Mr. Turner was distressed about his relationship with his oldest daughter. On the one hand, he feared that she would not comply with any limits he tried to place on her behavior, so their difficulties would intensify. On the other hand, he was upset with himselffor being passive rather than assertive. With the therapist, he generated alternative explanations for his unassertiveness and determined the minimal changes he wanted to see in his daughter's behavior. When he discussed these changes with his daughter, she surprised him by agreeing to try to change. She also requested changes, for example, that he be less critical of her. As a result, he became more hopeful that their relationship could improve and more confident about asserting himself.

In C-CT, Mr. Turner became very active and "took charge" of the sessions. He first reported on his successful use of coping skills, complete with specific examples. By reviewing successful experiences with these skills, the therapist encouraged Mr. Turner to take credit for the changes he was making in his life. As C-CT was nearing an end, the therapist had Mr. Turner review the major changes he had made over the course of treatment. Mr. Turner stated that over the course of therapy he had come to see that he could be "proud to be average," that he had "permission to be imperfect," and that he had multiple important roles (father, choir director, friend), in contrast to his former self-view as someone who must please everyone and always achieve perfection. He also recognized the importance of using the social support of members of his church, of prioritizing family time, and of taking care of himself.

In the final C-CT sessions, therapy focused on termination and relapse prevention. Mr. Turner was encouraged to view treatment outcome not in terms of success or failure (i.e., being or not being depressed), but as an ongoing collaboration to examine evidence that the interepisode interval had increased. He also was encouraged to use skills such as logical analysis and cognitive restructuring to shorten any episodes of depression, should they recur. The therapist worked with Mr. Turner in identifying and handling future stressors. Together, they predicted that either job or relationship stressors could be associated with depression recurrence, for example, if the church failed to meet its budget (resulting in a salary cut), or if he received repeated negative feedback from the choir. They spent session time rehearsing ways to cope with excessive responsibility, such as practicing ways to delegate responsibility. In addition to identifying future stressors, the therapist worked to change Mr. Turner's views of future sad mood and hopelessness, to think of them as signals for treatment seeking rather than for planning suicide. Finally, the therapist made sure that Mr. Turner knew when and where to seek help.

REVIEW OF EFFICACY RESEARCH Outcomes with Formulations of C-CT for Adults

The problem of relapse and recurrence after acute-phase treatments, including A-CT, has been recognized for decades and underscores the need for preventive treatment (e.g., Elkin et al., 1989; Klerman, DiMascio, Weissman,

Prusoff, & Paykel, 1974; Thase et al., 1992). Below we review research testing relapse/recurrence prevention with C-CT, including the "formulations" that Jarrett and other developers have tested. A meta-analysis of this literature is available (Vittengl, Clark, Dunn, & Jarrett, 2007). Empirical support for CT for medication-resistant and partially remitted depression is reviewed by Fava and Fabbri, Chapter 5, this volume.

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