Transitioning from ACT to CCT Avoid the Discontinuation Effect

Based on the operant conditioning literature, Jarrett (1989) used fading the schedule of therapy sessions as a tool for reducing relapse and recurrence. It appears that patients with depression are exquisitely sensitive to abrupt changes in the schedule of treatment and may develop symptoms when the schedule is thinned or stopped abruptly, regardless of the type of treatment. This so-called "discontinuation effect" has been observed not only with CT (Jarrett et al., 1998),but also pharmacotherapy (e.g.,Baldessarini et al., 1996). To reduce the impact of this effect, it is important to provide the patient with an expectation and rationale for the change, and to thin the frequency of sessions gradually, thus avoiding abrupt and/or unexpected discontinuation of sessions and/or rapid shifts in the time between sessions.

The 8-month, 10-session "formulation" of C-CT (Jarrett, 1989) respected this principle of thinning in the following manner. The continuation phase followed a 3- to 4-month, 20-session A-CT aimed at reducing symptoms, facilitating basic skills, and increasing adaptive functioning. During A-CT, the first 16 sessions were provided twice a week and the last four sessions were thinned to once weekly. During C-CT, the first four sessions occurred every other week, then the remaining six sessions occurred monthly. If a crisis arose, or if relapse appeared eminent, one of the 10 sessions could be scheduled as needed. When rescheduling sessions, therapists attempted to approximate the original plan, gradually thinning the schedule of sessions across the 10 months to minimize discontinuation effects.

A comparable process also occurs in the therapy itself. During A-CT, the therapist emphasizes the importance of mastering and using the crucial skills of CT independently, proactively, and when negative affect occurs. As the therapy advances, the therapist encourages patients to take more "control" of the therapy and to apply the critical skills to new problems and situations independently. Therapists "fade" direct guidance of the session, and patients assume greater responsibility. For example, therapists can promote such independence by asking patients to set and prioritize the agenda, to identify what coping strategies helped previously to reduce similar symptoms, to design homework assignments, and to conduct their own "therapy sessions" at home between sessions and on a regular basis. The therapist's goal is for the patient to attribute gains in adaptive changes in thinking and other behaviors to using understandable and easily accessible compensatory skills. The assumption is that mastering these tools is the first step to being able to use them in times ofhigh need, and to making their use automatic and habitual.

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