The Typical Course Of Therapy

Although the description of the process of CT sessions is important to learn and to use in treating depression, none of the processes I have discussed really address the content of the treatment of depression, or what I described earlier as "the work" phase of treatment. Unfortunately, there is no single "cookbook" or formula for treating depression. Every patient is unique and presents with his/her particular history, past efforts to overcome depression, comorbid problems, schemas, and current resources. What is presented below, therefore, is more of an overall guide to typical phases of CT for depression (cf. Beck et al., 1979;J. S. Beck, 1995,2005; Gilbert, 2001; see also Beutler, Clarkin, & Bongar, 2000).

One way to conceptualize the overall treatment of depression is as a series of three loosely connected phases. These phases tend to have different treatment targets; therefore, they require somewhat different intervention techniques or methods. It is important to note, however, that these are not lockstep phases, because the targets of intervention in one domain may continue for some time into therapy, even while other areas of intervention are introduced. Furthermore, if the course of treatment is not steadily in the positive direction, it may in some cases be necessary to "go back" to issues and interventions used earlier in the process of treatment.

Figure 1.2 is an attempt to show how these phases of treatment roughly relate to symptom change in a "typical" case of depression. Approximately the first one-third of treatment is focused on behavioral change; the middle one-third of treatment, on negative automatic thoughts; and the final one-third of treatment is focused on the assessment and modification of core beliefs and schemas. Typically, the first phase of treatment is associated with the greatest reduction in depressive symptomatology, because over half of the changes in symptomatology takes place within the first six sessions of treatment. The second phase of treatment is usually associated with more gradual but continued reduction in levels of depression. Patients typically transition from meeting the diagnostic criteria for major depression to no longer meeting such criteria during this middle phase of treatment. By implication, the third phase of treatment is largely conducted with a patient whose depression has recently remitted. Here, the focus shifts to understanding the genesis of the most recent or of other, past episodes of depression, examining vulnerabilities for future relapse or recurrence, and providing interventions that emphasize relapse prevention. Each of these phases is described in turn below, along with a description of some of the typical interventions.

Clinically depressed

Not clinically depressed

—__^

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Emphasis on behavioral change; behavioral activation interventions

Emphasis on negative automatic thoughts; cognitive restructuring

Emphasis on identification and change in core beliefs and schemas

FIGURE 1.2. Hypothetical progress in CT for depression (based on BDI-II scores), and targets of intervention.

The Early Phase of Treatment

The first aspects of CT for depression emphasize increasing the engagement of the patient in his/her environment and restoring functioning as quickly as possible. Decreased motivation, low energy, and tendencies toward avoidance or social withdrawal are all primary features of depression that need to be addressed if other cognitive work is to be effective. The goals of this phase of CT, though, are not only to increase activity and reduce depression levels but also to begin using various activities to generate a CT conceptualization of the case.

Some common methods are used in working with depressed patients in the earliest phase of CT. For example, most therapists want to understand the patient's typical day: how active he/she is during the day; his/her sleep cycles; and any unusual patterns in the patient's arousal or activity patterns. The therapist can gain this information by inquiring about a typical day, or a recent specific day, but such information is subject to presentational biases on the part of the patient, his/her embarrassment about activity patterns, depression-related distortions, memory problems, or simple forgetting some activities. For these reasons, cognitive therapists commonly ask patients to complete an activity schedule as homework following the first session. This assignment may be used more systematically to record patients' activities, because it requests that they indicate major activity in 1-hour time slots throughout each day. Some therapists also ask patients to indicate activities that are associated with mood changes, so that they can see which activities have positive or negative associations for patients. Another possible strategy is to ask patients to track events associated with mastery (success, accomplishment) or pleasure (fun, enjoyment), both to determine the frequency of such activities in patients' lives and to see whether their occurrence is associated with changes in the patients' moods. Indeed, activity schedules can be used to track any type of event or activity that the therapist and patient think might be related to changes in mood.

In addition to the benefits of monitoring the relationship between activities and mood, use of a more structured activity scheduling exercise offers three other advantages. First, it is an explicit example of the use of homework in CT, which the therapist should have described as a key part of the treatment. Second, it offers an "incidental" way to assess the patient's ability to enact agreed to homework. As described earlier, one of the principles relative to homework is that the therapist should always inquire about it at the start of the next session. As such, the assignment of activity monitoring in the first session can be a fairly easy way to socialize the patient into the process of homework. Third, the evaluation of activities is a natural precursor to scheduling specific activities that use the same activity schedule method.

Activity scheduling is typically done as a graded activity. As such, the first scheduled activities are simple tasks that can be accomplished in fairly discrete time periods. These may be "stand-alone" events or activities (e.g., pay the bills), or they might constitute the first steps in an elaborate, multistage process that needs to be planned over a series of weeks (e.g., systematic financial planning and budget setting). Either way, the activities need to be perceived as relevant to the patient's overall goals. They also need to be sufficiently challenging to the patient, at his/her current level of depression, to be seen as a success experience, but not so daunting as to prove impossible.It is relatively common for depressed patients (especially in the early stages of treatment) to perceive that they need to accomplish a lot, to set unreasonable goals as a consequence, then become frustrated and "give up." The therapist's role is to help the patient set reasonable goals, and to stage activity scheduling to be successful.

Activity scheduling provides an opportunity to examine patients' tendencies to predict future outcomes and to judge past ones. A common part ofactivity scheduling is to ask patients to predict their likely ability to do the assigned activity, as well as the likely outcome if they do so. If the patient makes a negative prediction, the therapist can ask some questions to determine whether this prediction represents a negative bias or might have some factual basis. If there is a good reason for concern, then therapist and patient can scale down or reconsider the homework it in its entirety. Sometimes the exercise of predicting the outcome of homework reveals an impediment to completion of the homework. If so, patient and therapist can problem solve the issues that are implicated, and either reassign or revise the homework. For example, sometimes it becomes clear through these discussions that the patient lacks some required social skill or other behavioral competence to do an assignment, and behavioral coaching or instruction may be necessary as a prerequisite to assigning the activity. Sometimes, a patient may have the apparent skill to complete the homework, but predicts no benefits, even if they exist. In such cases, the therapist can reevaluate with the patient whether this prediction is valid or yet another example of depressive thinking that needs to be evaluated against the experience of actually doing the homework. Another advantage of having the patient predict the likely success of behavioral assignments is that these predictions can then be contrasted with the patient's success with the homework assignment. It is fairly common for depressed patients to succeed with homework (if it is skillfully set), but then to minimize its value or their role in its successful completion. If this tendency toward minimization occurs, it is important for the therapist to ensure that the "facts" are established, so that the patient is compelled to give him/herself the deserved credit for homework completion. Also, if a patient is identified as someone who does not make internal attributions for success, this tendency can be incorporated into the next behavioral assignment, with the therapist acting as a kind of "guard" against minimization or externalization of successes. Importantly, a discovered tendency to minimize can be used as part of the emerging case conceptualization. For example, it is likely that a patient who predicts difficulties in life's tasks and/or minimizes success has some general sense of inadequacy or incompetence. Discovery of the domains in which these issues emerge help to sharpen the therapist's understanding of the patient's particular vulnerabilities and depressive schemas.

In addition to behavioral activation, another general technique in the early phase of CT is problem solving, which is particularly useful when the nature of the problem(s) a patient brings to therapy seem to be based more on verifiable events and less on negative core beliefs. For example, an immigrant coping with the stresses and strains of life in a new country, who shows signs of depression due to this adjustment, may be better served by a focus on language training and connection with social service agencies than by a focus on negative thinking. Activity scheduling is often a part of the successful treatment of patients with real-life stressors, but the focus on negative thinking is likely to be less than that in patients with fewer objective stressors.

Often specific symptoms or problems commonly associated with depression respond well to focused behavioral interventions. Sleep disturbance, for example, can often be ameliorated with several behavioral rules, such as the development of a regular sleep cycle, a change in bedtime habits, use of the bed only for sleep and sex, not permitting naps, or a change in the sleep environment (e.g., removing televisions or other distractions, ensuring the bedroom is as quiet and dark as possible), but cognitive interventions are also helpful (cf. Harvey, 2005). Low appetite can often be improved by setting regular meals, disallowing snacking, improving the quality of the food ingested (e.g., fewer carbohydrates), and spending more time with food preparation (as opposed to eating fast foods). Low energy can be addressed through a gradual increase in physical activity, recognizing and adjusting to normal diurnal rhythms of the body, planning for improved food and nutrient intake, and better sleep. Paying attention to negative predictions or beliefs in each domain and overcoming these cognitive sets as problem(s) improve often are important parts of treatment.

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