Cultivating the Therapists Mind Set to Work Effectively with Chronic Depression

Most standard CT texts do not give a great deal of attention to the treating clinics contribution to therapy outcome. Expert opinion and research evidence suggests that experienced clinicians achieve better outcomes than novice therapists when working with patients with more chronic presentations (Burns & Nolen-Hoeksema, 1992). Indeed, with regard to acute depression, the application of the standard Beckian treatment protocol (Beck et al., 1979) is considered the bread and butter of CT. Often there is an assumption that this same protocol is easily and readily translated to the treatment of more chronic and refractory presentations. When protocols fail to yield their intended results, the source of the problem is often located with the limitations of the intervention itself or the complexity of the patient presentation. Rarely is attention given to therapist qualities and skills that are likely to contribute to a beneficial outcome. Let us look at each of these in turn.

Therapist Personal Qualities

McCullough (2000) observed that fundamentally, in therapy, chronically depressed patients need to have an experience of engaging with a "decent, caring, human being." This is a position we also endorse. Chronically depressed patients can present considerable obstacles to the therapist conveying warmth and care, and there is the potential for supposedly therapeutic encounters to be damaging, unless the therapist has some capacity to recognize and manage his/her own contribution to interpersonal encounters in therapy. The therapist also needs to be consistent and reliable, and have the tenacity to stick with the therapy process and structure, and remain proactive, often in the face of extreme hopelessness, helplessness, and negativity.

Importantly, the therapist needs to be motivated and have an internal sense of confidence and that he/she can help the patient. It is very easy for the therapist taking on a patient's hopelessness and negativity to reach the point that he/she dreads the next session and is rendered powerless by his/ her own automatic thoughts about perceived inabilities as a therapist or the intractable difficulties that place the patient beyond help. To counter this and to work effectively with patients with chronic depression, the therapist needs to adopt a certain mind-set, which is perhaps summed up by the phrase "Everything is grist for the mill." What we mean by this is that the therapist is accepting of the territory he/she is in (no matter how difficult)

and works with the patient to use the difficulties, so that they work to the patient's advantage to progress in therapy. From this position there are always opportunities to learn and understand. Thus, for example, even incomplete homework assignments are not a waste of time. Collaboration can be fostered and responsibility for change can be shared when the therapist and patient ask, "What can we learn from this?" and "How does this develop our formulation?" It is important to emphasize the need for an equitable balance between optimism and realism in taking this mindful position, so that the messages given to the patient induce sufficient hope to motivate the patient's engagement but are not so unrealistic that they raise impossible expectations in the patient regarding the therapist and the therapy.

Therapist Skills

Increasingly, the CT literature is turning its attention to issues related to the training and clinical supervision of cognitive therapists (Padesky, 1996). It is our view that clinical outcomes for patients with chronic depression will be enhanced if the treating clinician has undertaken robust CT training; has extensive clinical experience working with this patient group; and is backed up by an effective clinical supervisor who has undertaken specific CT training and who is experienced in working with chronic depression.

A standard feature of all CT is explicitly sharing with the patient a cogent treatment rationale. The aim is to help the patient to understand at an experiential level the connection between specific experiences in his/her daily life, his/her emotional responses to these experiences, and the thoughts and thought processes, biological/physiological symptoms, and behaviors that occur at these times. There is a specific emphasis on how these domains feed into each other to create a vicious circle maintenance cycle.

This socialization process is usually initiated at the end of the first assessment session. It is important that the model not be presented in purely generalized and abstract terms, because this only enhances the global, overgeneral processing of information that characterizes chronic depression. Traditionally, CT uses metaphors to illustrate the treatment rationale (e.g., "You are lying in bed at night and you hear a loud bang. What is your first thought?"). In our experience, such metaphors may be less useful in chronic depression. We strongly encourage use of a concrete, recent example (the last 2-3 days) from the patient's experience to illustrate the vicious circle. In addition recounting the event needs to be located in time, place, and person, and recalled in the first person, present tense. For CT to be effective, the patient needs to engage emotionally at an experiential level. Therefore, the treatment rationale needs to have a high degree of personal relevance and emotional meaning to the patient. This is more likely to be achieved with the use of recent, personally relevant material that contains some emotional resonance. Given the role that cognitive and affective avoidance play in the maintenance of chronic depression, the use of abstract metaphors is more likely to enable the patient to distance him- or herself from the socialization process and declare that the example in the metaphor is not relevant to his/ her particular circumstances. There is, however, a need for a note of caution.

How the model is communicated to the patient is important. Given the cognitive deficits that characterize chronic depression, the patient may find it hard to remember what has been discussed. In addition, the patient's rigidly held beliefs might result in subsequent distortion of any conclusions. It is therefore advisable to diagram the vicious circle, with the patient example included, on a piece of paper for the patient to take home. Again this needs to be communicated sensitively. Many patients do not see words written on the paper. They see themselves, and this has potential to escalate feelings of humiliation and hopelessness. In addition, a supplementary handout that reiterates the treatment rationale is vital. An audiotape of the session containing the treatment rationale is also beneficial.

It may also be helpful with some patients to include cognitive processes within the treatment rationale, for example, negative, overgeneral, and black-and-white thinking; rumination; and depressive intrusive memories. This can be particularly effective when a patient cites an example of an incident that affected his/her mood over several hours. This enables the patient to incorporate the idea that the lower the mood, the more negative, black-and-white, and overgeneral the thinking, and the patient becomes less active and more internally focused. This can give rise to rumination and the intrusion of depressogenic memories from the past. The use of the metaphor that thinking becomes like ink on blotting paper can be very helpful in the beginning to engage the patient in a metacognitive perspective in which he/she observes not only the content of his/her thinking but also how he/ she thinks when depressed (negative, over general, black-and-white, and ruminative thinking and accessing past unpleasant memories), and contrasting this with his/her thinking when in a less depressed mood.

One of the key goals in sharing the treatment rationale is to engender hope. One means of engendering hope is to strike an optimistic but realistic tone with the patient regarding what CT can achieve. Often, therefore, it is more helpful to sell the patient on the idea that CT may not cure the depression, but it may have an impact in terms of improving function and symptom management as part of a treatment package that may include medication and social inclusion initiatives.

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