The Final Phase of Treatment

The cognitive model of depression assumes that individuals who become depressed generally have schemas or core beliefs that make them vulnerable to precipitating events (Young, Klosko, & Weishaar, 2003). More generally, according to the cognitive model, everyone has schemas that are the heritage of early experience, cultural and media messages, peer relationships, a history of mental health or disorder, and other developmental issues. Hypothetically, every person has his/her own areas of schema vulnerability. These vulnerabilities remain "latent," however, unless activated by relevant or matching triggers. For example, a perfectionist is theoretically vulnerable to depression if he/she experiences failure or lack of perfection, but he/she does not demonstrate depression as long as his/her perfectionistic goals are met.

As I noted earlier, by the time that an intervention addressing core beliefs takes place in CT, the patient often is no longer clinically depressed. Rather, he or she is most likely a recently recovered depressed patient, or "in remission" (American Psychiatric Association, 2000). Many patients continue to exhibit residual symptoms (Gollan, Raffety, Gortner, & Dobson, 2005; Paykel et al., 2005), and the gradual elimination of these symptoms remains an important goal of treatment, if possible. At the same time, the focus of therapy often naturally shifts to an examination of broader themes that have emerged over the course of treatment, to the identification of risk factors that led the patient to develop depression, and to a consideration of relapse prevention. Within the CT framework, this work is accomplished through the assessment and intervention addressing core beliefs.

Assessment of core beliefs may be accomplished with a number of methods. Often, patients' beliefs emerge through consideration of the distressful situations they describe. For example, if a patient consistently reports thoughts about being judged harshly by others, it is fairly easy to identify a core belief related to concerns about inadequacy and/or a harsh social environment. Sometimes, patients realize these themes themselves and spontaneously report them to the therapist. Other times, the therapist sees the patient's interpretive consistency across situations and can offer a tentative interpretation of this behavior as a reflection of an underlying or core belief. One strategy to accomplish this type of awareness is through a review of the various types of events that have led to similar distressful reactions over the course oftherapy. Patient and therapist can engage in a mental "factor analysis" to look for common meanings ascribed to these events and that bind them together.

A specific technique developed to determine the broader implications that a patient assigns to difficult situations is called the "downward arrow technique" (Burns, 1980). This technique begins with the identification of a set of negative thoughts related to a specific situation. Rather than examining the evidence or generating alternative thoughts to dispute these negative ATs, however, the therapist asks the patient to entertain the thought for the moment that his/her negative thoughts are realistic and that no alternative thoughts exist. The therapist then asks the patient to generate the logical conclusion from this idea; in effect, the therapist asks, "So what if these thoughts were true?," but without any effort to resist negative thoughts that might emerge. For example, a gay male patient wanted to form a new intimate relationship, but after an initial date, the other man refused to provide his phone number. The patient automatically thought, "He has rejected me." The patient was asked to consider what it meant if he was actually rejected, and he quickly responded that he was likely never to see the man again. When asked to consider the implication of this second "fact," the patient said it meant that he would likely be alone again for a while. He generalized the implication of this "fact" to mean that he likely would never be in another relationship, which meant he could never be fully happy in his life, and that he was probably an unlovable person. Thus, through the examination of the "downward" implications of a single rejection event, it became clear that this patient's underlying belief was one of unlovability, even though part of his prescription for lifetime happiness was being in a loving relationship.

The downward arrow technique can be employed in real-life situations and is effective when used with reference to recent, acutely distressing situations. It can also be employed in hypothetical situations, however: "What would it mean to you if. . . ?" The therapist can also conduct a downward arrow analysis of a real, recent life event, then modify it slightly in the patient's imagination to see whether the same or different implications are generated. The strategy of generating hypothetical circumstances similar to actual events is an efficient way to identify subtle aspects of core beliefs, without waiting for these events to actually occur. Yet another, more risky, strategy for identifying core beliefs is to design homework to test out their possible operation. In the previous example, it might have been possible to get the male patient to agree to attempt another date, while paying attention to any activation of anxiety or fear of rejection that might be underpinned by a belief of unlovability. Through the examination of such repeated events, the activity of core beliefs can be exposed.

All of these strategies are effective in the assessment or identification of core beliefs that operate across a number of specific situations or events in the patient's life. It is worth noting that the timing of these assessments is a critical clinical decision. It is relatively easy to use the downward arrow, for example, particularly if the patient is already somewhat distressed and the negative automatic thoughts are accessible. Typically, though, the technique ends with the patient recognizing that he/she has a negative core belief. Thus, if this technique is used too early in the course of therapy, before the patient has some resiliency, and/or his or her depression levels have already been ameliorated to some extent, the patient may possibly feel worse after the technique. On the other hand, if the therapist waits until the treatment has progressed too far, the patient may have difficulty accepting the "So what?" question at face value, and may not be able to generate the negative interpretations that might have emerged earlier in the course of therapy. Thus, it is a matter of some skill to use this type of technique early enough in treatment that some of the patient's negative thinking is still accessible, but not too early to expose a raw belief that might be overwhelming to the patient.

Once negative beliefs have been identified, the therapist needs to help the patient to complete his/her own case conceptualization. This understanding is essential to any belief change that the therapist might attempt. One strategy is for the therapist to share with the patient the case conceptualization that he/she has generated. This model may be drawn in the form of Figure 1.1, if that would be helpful to the patient. Other diagrammatic ways to represent the cognitive case conceptualization (e.g.,J. S. Beck, 1995) review early historical factors related to the emergence of core beliefs, the life assumptions that the patient has adopted (typically in the form of conditional assumptions, as in "If I am unlovable, then I need to stay out of relationships"), and the situations seen in therapy that conform to the conceptualization.

In addition to the clinically derived case conceptualization methods described earlier, it is also possible to use questionnaires to identify core beliefs. Three such measures include the Dysfunctional Attitudes Scale (DAS; Beck, Brown, Steer, & Weissman, 1991), the Sociotropy-Autonomy Scale (SAS; Bieling, Beck, & Brown, 2004; Clark & Beck, 1991), and the Schema Questionnaire (SQ; Young & Brown, 1990). The DAS yields endorsements of a series of potentially dysfunctional attitudes, written in the form of conditional statements. It has been factor-analyzed into two main dimensions, related to Performance Evaluation and Approval by Others (Cane, Olinger, Gotlib, & Kuiper, 1986). The SAS was created specifically to assess sociotropic (interpersonally dependent) and autonomy-related (achievement) beliefs, and this factor structure has also been supported in research (Clark & Beck, 1991). The SQ was rationally developed to measure 11 different types of schemas, and is related to Young's schema therapy-focused version of CT (Young & Brown, 1990; Young et al., 2003). The SQ has the clinical utility to differentiate among these schematic dimensions (Schmidt, Joiner, Young, & Telch, 1995). It yields a rich assessment of core beliefs/schemas and can be used as an adjunct to the clinical derivation of schemas to buttress or challenge the emerging case formulation.

Once the conceptualization of the core beliefs has been accomplished, and patient and therapist concur about their roles in the development of dysfunctional thinking, behavior, and emotional patterns, the question shifts to one of change. This process starts with the identification of a reasonable alternative belief to the dysfunctional one that has been identified. It is critical that this alternative belief be one that is attainable and desired by the patient. Therapist and patient can discuss the advantages and disadvantages of both the original and alternative beliefs from the perspective of short-and long-term consequences. Often this analysis reveals certain historical and/or short-term advantages but long term disadvantages of the dysfunctional beliefs, including increased risk of depression. The alternatives typically have better long-term consequences but often entail short-term discomfort and anxiety, changes in social relations, and even a "personal revolution," if the degree and type of change is dramatic.

If the patient remains committed to change after the discussion of the implications of changing core beliefs, then a number of techniques can be adopted, including public declarations of the intent to change, clarifying the "old" and "new" ways to think and act (or even to dress and talk), or changing relationships and the personal environment so that they are more consistent with the new schema that is being cultivated. One particularly powerful change method, the "as if" technique, involves discussing how a patient would think and act if he/she had truly internalized the new belief, then structuring behavioral homework "as if" the patient had actually done so. This technique potentially allows the patient to discover that he/she can live life using the new beliefs. It also has a reasonable probability of engendering negative reactions from others in the social environment, so these reactions must be anticipated. Part of this planning may include discussion of assertive ways for the patient to communicate his/her desire for change and the need to modify others' cognitions or beliefs about him/her.

Sometimes the discussion of the implications of schema change leads a patient to reconsider the advisability of changing his/her schemas. For example, a patient who has previously seen herself as incompetent and has developed interpersonal relationships that support this belief (i.e., in which others also view her as incompetent) may wish to change this self-schema. Although such a change has definite benefits for her, it also carries the risk of interpersonal stress and rejection from people in her current social circle. Thus, there is a "cost" associated with schema change, even if the long-term benefits are quite positive. From my perspective, it is entirely the patient's right to step away from schema change. The therapist's obligations in such an instance are not only to validate the patient's right to make that decision but also to discuss the implications of this decision, including the risk of relapse. The clinical focus then becomes one of accepting and coping with ongoing negative beliefs. In such cases, it is also important to encourage the patient's continued use of the behavioral activation and cognitive restructuring techniques learned earlier in therapy.

Termination of CT for depression typically involves a review process, as well as a planning phase. The review includes the case conceptualization, and the various techniques that the patient learned and used over the course of therapy. This review clarifies the extent to which initial treatment goals have been attained, and whether any goals remain. Sometimes, this review leads to the renegotiation of continued therapy for a short period of time, around a discrete goal, but more often it leads to a discussion of how life is an ongoing process that always involves change. Another typical process is planning for the future and anticipation of possible relapse (Bieling & Antony, 2003). This part of the termination process includes discussion about strategies to achieve ongoing goals, how to deal with ongoing or anticipated problems, how to recognize the early warning signs of depression, and how to keep the techniques the patient learned over the course of therapy active in his/her life. In the latter regard, one possible strategy is the use of a "self-session," in which the patient chooses a time to sit down and identify current issues, review cognitive and behavioral strategies to deal with these issues, and assign his/her own homework. Self-sessions also serve as a bridge to treatment termination, if the final sessions are spaced out over time.

It is often helpful to arrange one or more follow-up appointments (i.e., booster sessions) in the weeks following treatment discontinuation to see whether any new issues have emerged and to reinforce the lessons of treatment. Cognitive therapists typically predict risk of relapse or recurrence of depression and often have permissive rereferral policies that are predicated on the idea that learning new techniques takes time and practice, and that their role is not to "cure" the patient but to aid him/her in skills development and use. Because it is also not possible to anticipate all eventualities over the course of a single treatment process, sometimes a few booster sessions can be an effective way to supplement a course of CT for depression.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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