Overcoming Depression: A Cognitive Therapy Approach Therapist Guide 2nd Edition (Treatments That Work)

Overcoming Depression

EDITOR-IN-CHIEF

David H. Barlow, PhD

SCIENTIFIC ADVISORY BOARD

Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

Overcoming Depression A COGNITIVE THERAPY APPROACH SECOND EDITION

Therapist Guide Mark Gilson • Arthur Freeman • M. Jane Yates • Sharon Morgillo Freeman

1 2009

1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2009 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. ISBN-13 978-0-19-530000-0

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Printed in the United States of America on acid-free paper

About TreatmentsThatWork TM

Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps, inducing harm. Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This new series, TreatmentsThatWork™, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-by-step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing

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ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging healthcare system, the growing consensus is that evidence-based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This therapist guide is designed to give mental health professionals the necessary tools to assess and treat a broad range of mood disorders, particularly depression. Based on the principles of cognitive-behavioral therapy, this program helps patients develop a set of coping strategies and skills to proactively deal with potential depressogenic issues. Using the acronym BEAST, treatment modules address biology, emotions, activity, situations, and thoughts. In-session exercises as well as home assignments help motivate the patient and allow for the monitoring of progress. The treatment is active and directive and can be used in conjunction with medication. David H. Barlow, Editor-in-Chief, Treatments ThatWork™ Boston, MA

References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–878. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

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Acknowledgments

When Aaron T. Beck began to develop his work on depression in the early 1960s, he also began a revolution in understanding and treating depression. Over the past decades, his work in cognitive therapy has evolved in clinical sophistication, empirical support, and popularity. The Academy of Cognitive Therapy, The Association of Behavior and Cognitive Therapy, and the International Association for Cognitive Psychotherapy, along with many professional journals are now dedicated to the advancement and dissemination of the cognitive-behavioral model. The authors have had the good fortune of being either faculty (Art Freeman and Mark Gilson) at the Center for Cognitive Therapy at University of Pennsylvania under Dr. Beck’s wise guidance and/or having extensive contact with the organizations he represents. We are grateful for what Aaron T. Beck has offered to us and, by extension, to the clinical community. David Barlow, PhD, is a pioneer in the development of psychology as an applied empirical science, and he tirelessly attempted to garner respect for psychotherapy as a credible means to help people change for the better. His invitation to Mark Gilson to begin this project will always be considered an honor and a privilege. A special note of appreciation goes to another person who has delivered anthems of hope in times of hardship. Pete Seeger, called the father of American folk music and singer of songs such as We Shall Overcome and Turn, Turn, Turn, offered suggestions for this book when it was first published. As a mentor to Mark Gilson, his messages (and his life) of perseverance during times of unfairness and struggle have helped so many and remain an inspiration. Simple ideas, humility, and sincerity

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of purpose can move mountains, and Pete has taught many people to hold on and find hope in the midst of unhappiness and suffering. Coauthor M. Jane Yates deserves special recognition for doing more editing and rewriting than anyone else on this project. When any of the other authors were delayed, she stepped in and saved the day. Sharon Morgillo Freeman gives a heartfelt thanks to the many patients whose individual stories and successes contributed to the development of the materials contained in this book. Without their wisdom, assistance, and input this book would not have been possible. To family and friends for your patience while time was taken away during the development and completion of yet another project; thank you for your love and support, it means a great deal more than you will ever know. Much gratitude is owed to Mariclaire Cloutier and Cristina Wojdylo at Oxford University Press for their incredible patience, tireless hours of editing, and support as well as friendship throughout this project. The editorial staff have contributed immensely to making the materials we put together readable without sacrificing the voice of the authors or the impact of clinical concepts and ideas. Thanks are no where near enough.

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Contents

Chapter 1

Introductory Information for Therapists

Chapter 2

Assessment of Depression

Chapter 3

Socialization

Chapter 4

Biology

Chapter 5

Emotions

Chapter 6

Activity

Chapter 7

Life Situations and Vulnerability

Chapter 8

Thoughts

Chapter 9

Relapse Prevention

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Chapter 10 Ending Treatment

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39 71 91 113

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Appendix of Forms

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Medications Chart

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References

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About the Authors

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Chapter 1

Introductory Information for Therapists

Background Information and Purpose of the Taming the BEAST (TTB) Program Depression has been called the “common cold” of emotional disorders. At some point, to some degree, for some length of time, with some degree of discomfort or impairment, depression has been an unwelcome visitor for many people. Sometimes it stays so long that it becomes familiar enough to name. Winston Churchill’s metaphor of his “black dog” implied that his depression was a constant companion. In our accumulated clinical experience of almost a century, we have seen this phenomenon all too often. The patient describes “it” (the depression) as returning or lingering or just hanging about. In applying cognitivebehavioral therapy (CBT) to the treatment of depressed patients, we have found it useful to anthropomorphize the depressive phenomenon in order to separate it from the individual. By doing this we can give the patient: (1) a focus for the therapy work, (2) an easy mnemonic for the multiple foci of treatment, and (3) a playfulness that can be used to challenge the negative depressogenic thinking and resulting emotional, physiological, situational, and behavioral sequelae. The acronym BEAST was developed as a way to personify depression and make the disorder more relatable. The goal of this program is to “tame the depression beast” and the acronym helps to organize and systematize the treatment protocol. B stands for behavior, E for emotions, A for activity, S for situations, and T for thoughts—all the areas to be addressed during therapy. The organization of the acronym does not suggest a hierarchy nor are we advocating for one in which any modality is ascendant. CBT is best conceived of as multimodal wherein each modality has a place and the sequence and amount of effort and focus

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depend on the treatment conceptualization, the patient’s motivation, support for change, particular genetic vulnerability toward depression, the therapist’s skills, the available time for treatment, and the establishment of reachable, reasonable, and parsimonious treatment goals. Toward meeting this goal the program, like most programs in the TreatmentsThatWork™ series, is linear in that there are specific stages of treatment. Generally, there is evaluation and diagnosis, collaborative treatment planning that includes setting realistic goals for therapy, orientation and socialization, introduction and utilization of therapy interventions that include assignments for the patient after each session, monitoring of progress, evaluation of goals being met, and termination of therapy. What differs in the TTB program is that we have specified modules that will be ordered and used in accordance with the assessment data and the conceptualization and focus for each stage of the treatment. Finally, the TTB program offers the therapist and the patient a roadmap for overcoming the “BEAST” and a systematic manner for attaining the skills so that future depressive experiences are less frequent, of shorter duration, of reduced depth, and cause less dysfunction.

Mood Disorders This program targets a broad range of mood disorders, including major depressive disorder, dysthymic disorder, bipolar spectrum disorders, cyclothymic disorder, atypical depressions, mood disorder due to a general medical condition, and substance-induced mood disorder. Two subtypes of mood disorders include seasonal affective disorder (SAD) and postpartum depression, while premenstrual dysphoric disorder has been proposed as a diagnosis for further study. We will also discuss and differentiate between adjustment disorders with depression and normal bereavement.

Development of the Treatment Program and Evidence Base Cognitive therapy was initially developed for the treatment of depression by Aaron T. Beck, M. D. Working at the Center for Cognitive

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Therapy at the University of Pennsylvania (also known as the Mood Clinic), Beck developed and refined his treatment over a number of years. His early writings on depression, Depression: Causes and Treatment (1972) and Cognitive Therapy and the Emotional Disorders (1979), culminated in development of his cognitive approach to treatment. In 1979, along with Rush, Shaw, and Emery, his classic treatment volume, Cognitive Therapy of Depression was published. Both Freeman and Gilson worked with Beck in these early years and were part of the cohort of early trainees in his model. Empirical studies that support the efficacy of cognitive therapy abound in peer-reviewed scientific journals. They span at least a 30-year period and continue to this day. Butler, Chapman, Forman, and Beck (2006) reviewed 16 meta-analyses that have investigated the efficacy of cognitive therapy. This study examined how cognitive therapy outcomes compared to the outcomes of various control groups in terms of their effect sizes. This study of studies showed strong support for the use of cognitive therapy for depression. Another meta-analysis of 28 scientifically controlled studies was done by Dobson (1989), again supporting the effectiveness of cognitive therapy outcomes for the treatment of depression when compared with other forms of treatment. Summarizing the research of the past 45 years is not an easy task given the volume of studies that have been and are being conducted. Garratt, Ingram, Rand, and Sawalani (2007) have provided an extensive review of the research literature supporting the efficacy of cognitive therapy for depression. They looked at the questions concerning cognitive therapy methods and found cognitive changes are associated with therapeutic improvement. They also found some evidence that suggests cognitive changes associated with pharmacotherapy are not as long-standing as those associated with cognitive therapy. Study on relapse in depression has indicated that negative depressive thinking even after successful experiences with cognitive therapy can reactivate it (Segal et al., 2006). Efforts at relapse prevention include imparting patients with skills that they can use whenever depressive events recur to help address setbacks with mood. The effectiveness of cognitive therapy in preventing relapse exceeded that of antidepressant medication in a controlled study over a period of two years (Dobson et al., 2008).

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There are some studies that show other treatments as being effective, such as interpersonal therapy (IPT) and pharmacotherapy (Elkin et al., 1989). Over the many years, the preponderance of studies lends strong support to the effectiveness of cognitive therapy in the treatment of depression.

Risks and Benefits of this Program There are several benefits of the TTB program. TTB helps the patient: ■

effectively cope with a depressive episode, whether it is a single episode or part of a recurrent pattern.

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develop a set of coping strategies and skills to proactively deal with potential depressogenic issues.

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develop the antidepression skills to help others, such as family members and friends, to more effectively cope with the patient’s depression or depressive episodes.

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develop a keener awareness of the signs and indicators that portend depression.

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develop a relapse prevention plan that can be used to prevent future episodes of depression or lessen its effects.

As for risks associated with this program, we are hard-pressed to identify any. Of course, there are always the risks inherent in working with a therapist who is not competent in the treatment skills required to conduct CBT. Adequate training and supervision in CBT is required before assuming competence in any therapeutic model and CBT is no exception. The program as outlined may be the “core” of a wider-scope treatment when depression is comorbid with other disorders, such as substance abuse disorders.

Overview of the Program The cognitive-behavioral treatment of depression is based on the cognitive model of depression (Beck, Rush, Shaw, & Emery, 1979),

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though the model has been enlarged and expanded over the past three decades. No longer focused exclusively on cognition, the CBT model includes strong behavioral, systemic, environmental, cultural, physiological/biological, and affective components. There are several dimensions to the TTB program. These include the treatment being:

Active The patient must be an active participant rather than a passive recipient of the treatment. The workbook encourages and supports this position. Dynamic The treatment is dynamic in two important ways. First, it focuses on the schema that the individual has developed over the years. Second, it views depression and its treatment as an ongoing and dynamic process rather than a static issue to cure. Psychoeducational The entire TTB program is skill-based and involves the patient enhancing his skill set. Collaborative Given the enervating nature of depression, the clinician must make an initial and ongoing determination of the patient’s ability to collaborate and commit to treatment. Initially, the collaboration may be 80/20, with the clinician carrying the major load of the therapy work. As the patient is able, he can shoulder a greater proportion of the therapy load. Directive The clinician maintains a directive stance throughout the therapy. The assessment, conceptualization, and implementation of the treatment must be “choreographed” by the clinician. The therapist’s mastery of the CBT/TTB model and ability to conceptualize will predict how effectively the choice of homework assignments and self-help efforts will be. Here-and-now While the past may be prologue, the treatment focuses on the sequelae and results of the patient’s early experience. Many, if not most of these experiences are coded in schema that actively direct the patient’s thoughts and actions in the present moment. The focus of treatment emphasizes how depression is maintained in the patient’s present life.

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Structured A common complaint for patients is that they need to organize their confused lives which leave them in disarray. By maintaining a high level of structure, and a minimum of “therapeutic wandering,” the therapy models a more focused and coping model for dealing with depression and life itself. Time-limited Time-limited does not refer to a specific number of sessions, but to a way of conceptualizing the therapeutic process. The process is viewed as having a beginning, middle, and end phase, with each element of the therapy assigned benchmarks for completion. Problem-oriented Patients often confuse problems with complaints. For example, they seek treatment for “depression.” Depression must be recognized as a complaint rather than a problem. The problems of depression are the affective, systemic, behavioral, and cognitive elements that together form the pattern labeled as depression, depressed, down, blue, sad, or dysthymic. Solution-focused The TTB program is designed to identify each of the critical elements of the depressive experience. The TTB program then arranges the issues in a hierarchy and then directly helps the patient to cope more effectively. Culturally relevant The patient’s sociotype, or set of cultural, familial, and gender-related schema are taken into account in designing and implementing the TTB program.

Alternative Treatments Interpersonal therapy (IPT) is similar to cognitive therapy in that it is short term and focused. However, it is based on psychodynamic and social learning approaches. It focuses on how personal relationships have impact on mood states instead of emphasizing thought patterns. The NIMH collaborative study in the 1980s gave empirical support to this approach. There is not as extensive research done on this model, but what does exist gives it merit.

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The Role of Medications in the TTB Program Antidepressant medication can be an important part of the overall treatment program. Patients who enter the TTB program may have sought and secured such medication from their physician or health care provider. While there are studies that show that CBT is as effective as or even more effective than medication, in treating certain depressive manifestations and states, we view the TTB program and medication as partners. Studies have shown that when patients who have been treated solely with medication discontinue its use, they are at greater risk for increased relapse and decreased coping approaches. For many reasons, the non-medical clinician can easily and reasonably partner with medical psychiatrists or other competent prescribers.

Outline of the Treatment Program Chapter 2 describes how the therapist in collaboration with the patient evaluates primary and secondary targets for the program. This helps the patient to gain a level of hope inasmuch as he can see that something, no matter how small, can be started. Given the individual’s negative view, this, in and of itself, can have a salutary impact. Subsequent to this introduction, the program will focus on the assessment of the depressive phenomena. Included in this part of the program is an evaluation of the components of depression and a focus on which module might offer the greatest gain and improvement. Chapter 3 focuses on the socialization of the patient to the CBT/TTB model more generally. This is especially important for the inexperienced patient who has never been in therapy and whose “experience” of therapy is only what he has seen on television, in the movies, or has gleaned from the therapy experience of others. For those individuals who have been in therapy before and have chosen, for myriad reasons, to not return to their previous therapist, the socialization to the concept and structure of therapy is essential to differentiate the TTB treatment from their previous mode of therapy. Other individuals have been working to self-treat their depression for varying lengths of time. For this type of

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patient, the TTB program is ideal in that it uses the patient’s high level of motivation and couples it with the structure and psychoeducational emphasis of this program. Finally, there are those patients who believe that they had exhausted all possible ways of treating their depression. The TTB program can energize patients and help them regain hope for relief of symptoms and for the future by virtue of its straightforward, here-and-now, and practical emphasis. Chapters 4 through 8 describe each specific treatment modality: the individual’s physiological and biological issues (Chapter 4), the affective dimension (Chapter 5), the behavioral dimension, which includes activity (Chapter 6), the situations or circumstances and environment in which the patient finds himself (Chapter 7), and the cognitive elements or thoughts (Chapter 8). Chapter 9 is of critical importance in that it emphasizes relapse prevention. How can the patient work to establish an environment that can ward off future depressive events or episodes? How can the individual equip himself? How can he control his experience rather than seeing himself as a victim of the next coming of the “black dog”? The last chapter outlines the termination phase of the program. The patient is helped to gain closure on the treatment relationship, become hopeful about the future, and confident by practicing the skills that are the core of the relapse prevention portion of the program.

Use of the Workbook In addition to this guide, there is a corresponding workbook available for program participants. The workbook contains psychoeducational information that patients can refer to in between sessions to reinforce what they learn in session with their therapist. The workbook introduces the patient to the concept of recency and primacy as an initial way to promote his own global assessment of how beliefs and mood fit on life’s timeline. Primacy refers to how early or profoundly traumatic events may influence thought, feeling, and behavior. Then there is recency or those events that have immediate impact on mood. It also

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contains worksheets and forms for use during in-session exercises, as well as for completing at-home assignments. Chapter review questions help patients gauge their understanding of the ideas presented and monitor their progress. The literal acronym of BEAST and the metaphor it offers can potentially help a patient see the phenomena of mood as something he can eventually understand and manage in collaboration with the therapist. A patient can begin to see a personal experiential ecology that is dynamic, potentially changing in total when any component of the BEAST is altered. The image of taming a potentially unruly creature speaks to both the element of risk and the possibility for improvement and transformation.

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Chapter 2

Assessment of Depression

Overview of Assessment Assessment is a multifaceted activity that underlies the therapist’s perspective of the patient, the nature of the problem (in this case, depression), the frequency of the depression, the amplitude of the depression, and the associated antecedent and consequential social, physical, affective, and environmental factors as they relate to the development and maintenance of the depression. In its simplest form, assessment involves data collection, a core and essential part of CBT. The more data, the better able the clinician is to make informed choices about the strategies and interventions in the therapy. The assessment frame or format might be direct observation, patient report, report of significant others, report(s) of other professionals, medical history, family history, psychiatric history, psychological screening, more extensive psychological testing, and the clinical interview. The clinician’s theoretical perspective, however, must be background for the assessment. For many treatment models, the theory is foreground. For example, in the traditional psychodynamic model of behavior, the problematic behavior of an individual is viewed as a symptom of some underlying, non-observable cause or conflict that may be out of awareness. Failure to understand and treat the underlying cause or conflict would lead to the patient continuing the problematic behavior or experience a symptom substitution for the identified behavior. In CBT, the theoretical formulation of depression is related to negative thinking, whether that cognitive processing style is individual formed, familial, or based on a biological vulnerability. The over-simplistic (and incorrect) model that thinking = feelings is best put aside. The

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interrelationship between biology, emotions, actions, situations or circumstances, and thoughts (BEAST) is the basis for this model and for this book. Data is essential to build a conceptual model of the patient. This would include the patient’s problems, environment, ongoing and situational reinforcers, and the individual’s goals and readiness to change. The assessment is, therefore, a focused, useful, parsimonious, systematic approach designed to facilitate the understanding of behavior and to provide a sound basis for clinical decision-making and the development of effective behavior change strategies (Haynes, Leisen, & Blaine, 1997; Haynes & Williams, 2003). Part of the assessment model explicitly includes what the patient has done to unlearn her maladaptive behavior, what has worked, and what has not worked in favor of change. The assessment process provides data about what the person does, the circumstances under which the depressive or depression related behavior commonly and reliably occurs, and how often the behavior occurs. It will clarify what has been used by the individual to decrease the behavior, what circumstances or timing are commonly and reliably involved in the increase in the depression, how long the depression lasts, and what is obtained, escaped, or avoided as a result of depressive symptoms (Bellack & Hersen, 1998).

Observation as an Assessment Tool Observation by a skilled, trained clinician is the most effective assessment tool. However, this is often difficult or even impossible in typical outpatient therapy due to limited time spent in actual observation of the individual. It is important for the clinician to obtain an adequate sample of the situations in which the criterion behavior is likely to occur. This sampling is essential to understanding the behavior in question. Scheduling and collecting observations across a variety of relevant situations is most beneficial. Limiting observations to a small number of situations may prevent a thorough understanding of the target behavior, especially if these situations preclude the expression of the target response (DiTomasso & Colameco, 1982). For some problems,

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setting the occasion for the response to occur may be necessary. Otherwise, waiting for situations to occur that include occasions for the response may be too time consuming and impractical (DiTomasso & Gilman, 2005). When possible, the behavioral observations are directly obtained in the natural environment where and when the behavior is occurring, either directly observed by another or self-monitored by the patient. Even in situations where observable behavior is coded in some fashion, the reliance upon inference is minimal.

Defining the Target Behavior The quality of the information obtained from the assessment depends upon clearly and explicitly defining the target behavior or complaint in question. Carefully and precisely delineating and operationalizing the critical components of the target behavior allow for clear discrimination of the occurrence and non-occurrence of the behavior under observation (DiTomasso & Colameco, 1982). It also serves to differentiate instances of the target behavior from other behaviors that could otherwise be confused with the target behavior. The clinician is advised to differentiate between patient complaints and patient problems. When individuals seek therapy, they often report broadly painted symptom pictures that take the form of complaints. Examples are terms such as depression, anxiety, panic disorder, or social anxiety. These terms have become the shorthand for the clinician and are typically used by the patient. The patient self-report, “I am depressed,” is, at best, a starting point for the assessment, not the conclusion. The complaint of depression may be viewed as untreatable. What becomes the focus of the assessment and later the treatment that derives from the assessment are the problems the patient has in effectively coping with a depressive episode. For example, for one patient, the predominant complaint of “depression” may involve weight change, sleep disturbances, and sadness. For another individual, the complaint of “depression” may involve suicidal thoughts and/or actions. For yet a third individual, “depression” may impact work life as the individual has problems with, or exhibits reluctance to, making decisions and following through. Because of the

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difficulty in direct observation of the complaint, the clinician has little choice other than to rely upon self-report measures as opposed to observational methods (Taylor, 1999). One example of a self-report approach is behavior-rating scales which rely upon a thorough representative sampling of the universe of behaviors that define a construct. Our approach to assessment is multimodal and focuses on more than one aspect of the behavior. Behavior is therefore more broadly defined and may include cognitive, emotional, situational, and physiological parameters. By engaging the individual to become a direct observer and recorder of her own private events, the assessment helps to make what may seem to be unobservable more observable or to give voice to the unspoken thoughts that now may affect her behavior. Of course, the assessment may incorporate observational information from more than one source. Possible informants include the individual as well as those who share the individual’s environment including family members, friends, colleagues, peers, medical doctors, and the like. Reliance on other observers helps to provide a fuller understanding of the target behavior from different perspectives. These differing perspectives can offer multiple views that are, in effect, contradictory. Longin (2004) studied a revision of the Beck Depression Inventory, Second Edition (BDI-II). She asked significant others and staff members to assess the level of depression of a patient by using a version of the BDI-II that was dubbed the BDI-O for Beck Depression Inventory-Other Report. The BDI-O was reworded in the third person so that “I feel sad,” was written as “He/She feels sad.” The results of the BDI-O were then correlated with the patient’s self-report. What Longin found was that there were significant differences between patient and staff and within the staff. Among the problems that she addressed were that the staff differed in experience, modality of treatment, and training and standardization of the BDI-O. Informants may shed light on some aspect of the problem behavior about which the individual does not have access or awareness. An important by-product of this process is that it may ultimately help those in the individual’s environment learn how her own behavior may be intimately tied to the maintenance of the individual’s depression. Observational data also serve to provide social validation about the change

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in an individual’s behavior, an important yardstick for determining the clinical significance of any change. Corroborative data are valuable in delineating specific circumstances and situations under which the depression manifests itself, that is, the problem behavior may be more likely to occur under one set of conditions than another. In this sense, certain situations may represent high risk situations and associated cues to which the patient and clinician need to be sensitive, aware, and alerted. If, however, the depression is found to differentially occur across situations, across time, with diverse social experiences, the exploration of the differences across these situations may provide helpful information about more subtle precipitating or maintenance factors for the depression.

Identifying Time-Associated Causal Variables Since the information derived from the assessment is used to select, design, and implement interventions, information about the frequency, duration, or amplitude of the depression provides only part of the picture. The assessment data essentially includes the circumstances under which the depressive behavior is likely to occur; a description of the target behavior itself; the patient’s associated thoughts, images, and feelings; and the consequences in the individual’s environment that may serve to reinforce and maintain the problem and any physical or physiological experiences that appear with the depression (DiTomasso & Gilman, 2005). The determination of factors serving to reinforce and maintain problematic behavior is crucial. By observing the impact a problem has on the individual environment, it is possible to identify possible positive reinforcement of the behavior. Assessment data are collected at baseline (when the patient enters treatment), during and throughout treatment and through follow-up after treatment has ended. The assessment is ongoing and built into the therapy. The clinician obtains a series of integrated snapshots of the depressive thoughts, actions, and feelings by sampling each across a variety of relevant contexts. The synthesis of this information provides a comprehensive view of the target problem yielding clinically useful information. Ongoing data obtained during treatment further informs

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the case conceptualization, either supporting the selection of treatments and interventions or necessitating a reanalysis of the problem and selection of other treatments or interventions. Data obtained during the treatment phase should confirm improvement of the problem over baseline. Follow-up data provide a measure of the stability of the behavior change; identify possible relapse, and the degree to which alternative ways of responding have been learned. In the assessment of the depression, continuous observation or selfreport is extremely valuable. The fact of knowing one is being observed or that one is observing oneself may produce reactive effects. Reactive effects occur when the knowledge of observation changes the phenomenon being observed. In short, the observations obtained when one is aware of the observation may not necessarily generalize to situations when observations are made without this awareness of the patient. From a clinical standpoint, reactive effects appear to occur in a direction that is congruent with treatment effects and although transient in nature may be initially confused with treatment effects (DiTomasso & Gilman, 2005).

Assessment Tools There are many possible behavioral assessment tools available. The exact nature of these tools depends upon the specific types of target problems being assessed. Methods of behavioral assessment include direct observation by another or self-observation in vivo, in vitro, or during performance on an analogue measure. Regardless of the specific tool selected or designed, a commonality across all tools is the monitoring of important and relevant aspects of the target response. For example, a behavioral assessment tool for monitoring depression might include the day, situation, symptoms, thoughts, depression levels, the time the depressive attack began, the time it ended, and associated behaviors. A mood diary that uses the Automatic Thought Record (ATR) would include the situation, feeling, rating of feelings, automatic thoughts, belief rating of the thoughts, specific type of cognitive distortions, adaptive thought, belief rating of the adaptive thoughts, re-rating of negative automatic thought, and re-rating of feelings.

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Beck Depression Inventory The Beck Depression Inventory (BDI-II) offers the clinician an extremely valuable and useful tool. It can be used to establish the baseline for the depressive complaint, but also evaluate the various contributing problems that coalesce into the complaint. Using the BDI-II at every session also offers the clinician a snapshot of the previous week or time between sessions. By having the patient complete the BDI-II prior to each session, and then by reviewing the scale as part of the session agenda, the therapist and patient can track changes in the overall assessment of depression, but also changes on a more subtle basis of the specific areas of difficulty. For example, if the patient’s typical score on the hopeless items of the BDI-II (items 2 and 11) change from patient ratings of ones to threes, the change must be put on the agenda to assess suicidality. Tracking the 21 items of the BDI-II and charting them for each session offers the clinician and patient a map of changes over time. Obviously, if there are no changes, the conceptualization and treatment must be evaluated. To provide valuable information, behavioral assessments must be collected under circumstances that ensure adequate representation of the problem. The BDI-II can also be used as an excellent homework tool. The patient can be given a supply of the BDI-II forms and asked to complete them at some set time during each day between sessions. This also encourages the patient to be more alert to changes over time and not simply a victim of some massive shift that seems to appear all at once.

Freeman Diagnostic Profile Another tool for assessment of baseline and future change is the Freeman Diagnostic Profile (Freeman & Freeman, 2005a) (See page 19). This profile is based on the DSM-IV TR (2000) criteria and requires that the clinician review each of the criteria with the patient. By ranking each criterion on a scale from 0 to 10, a profile of the severity of a particular criterion (problem) will be to the overall depression (complaint).

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The Freeman Diagnostic Profile: 1.

is based on the DSM-IV TR

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is user-friendly

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focuses on problems rather than complaints

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separates problems into component parts

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leads to treatment planning

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can be used to show patient areas of greatest concern

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is useful for evaluating change and progress

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helps supervisors to identify patient’s problems for supervision

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can be used to support need for additional therapy sessions

10.

can be used for all disorders (both DSM and ICD)

Patient Report The patient’s report of her experience of depression is important in that it is often the first statement of the complaint and is told from the patient’s view. The experience of depression as well as the effect of the depression are the direct results of the patient’s views about herself, her views about the world or her experience in it, and her view of the future. This “cognitive triad” is a useful tool for treating the depression (Beck, Rush, Shaw, & Emery, 1979; Freeman, Pretzer, Fleming, & Simon, 2004). Does the patient report the depression as “annoying,” or do they describe the depression as “overwhelming.” Is the depression something to be fought or handled, or does the depression fill their lives and leave them little hope for surcease. The Tracking of Mood (TOM) Form is an important tool for the patient to use as she progresses through the TTB program to show the incremental improvement in scores and ratings. You can introduce it to the patient in the assessment phase and explain it further in the socialization phase. Introduce the TOM as a valuable tool not only to track progress, but to assess what techniques are most useful and re-evaluate

18

FREEMAN DIAGNOSTIC PROFILING SYSTEM © FREEMAN & FREEMAN, 2005 REVISED EDITION

Patient Name:

Date of Assessment: Session #

MR#

Instructions: Record the diagnosis including the code number. Briefly identify the criteria for the selected diagnosis. Working with the patient either directly as part of the data gathering of the clinical interviews, SCALE the SEVERITY of EACH CRITERION for the patient at the PRESENT TIME. Indicate the level of severity on the grid. DIAGNOSIS (DSM/ICD) with Code: Axis I:

Code

Axis II:

Code

9 7 6 5 1

2

3

4

MEDIUM LOW

SEVERITY OF SYMPTOMS

8

HIGH

10

Axis III:

0

1

2

3

4

5

6

7

8

9

10

11

12

DESCRIPTIVE CRITERIA CRITERIA: 1

7

2

8

3

9

4

10

5

11

6

12

Do you believe that the above noted criteria are a reasonably accurate sample of the patients behavior? If NO, please indicate why: Are there reasons to believe that this individual is in imminent danger to self or to another person(s)? If YES, please indicate the danger and explain further in the patients medical record

YES YES

NO NO

19

the treatment plan. Instruct the patient to enter BDI scores, ratings of the individual factors, and an overall rating of satisfaction with progress. A copy of the TOM Form is provided in the appendix.

Report of Significant Others The information to be gleaned from significant others is not meant to replace or challenge the patient’s view, but rather to corroborate the patient’s view, provide additional information that the patient may not have or remember, and offer the outsider’s perspective. For example, a patient may report experiencing depression since her teenage years. A parent or older sibling may recall depressive episodes even earlier.

Report(s) of Other Professionals We view it as essential to obtain reports from any and all previous therapists. It would be important to factor in the view of these other therapists, along with what was tried in therapy, what worked and what did not work with this particular patient. Even if the previous therapist(s) had very different theoretical orientations, their view of the clinical behavior can be useful. Reports from occupational therapists, physical therapists, or any other treating professional can all shed light on the patient’s style of responding, motivation, and adherence to therapeutic regimen.

Other Things to Consider Medical History Data that can be garnered from the patient’s medical provider can shed light on medical, physiological, organic, or medication-related problems. If a patient has not seen her medical provider within the last 6 months prior to therapy, a check-up, with full blood work is essential. Use the Medical/Physical Information Sheet in the appendix to assess the patient’s medical history. A copy is also provided for the patient

20

in Chapter 4 of the workbook. Chapter 4 in this guide provides more information.

Family History A knowledge and understanding of family experiences of depression is important inasmuch as depression can often be traced through both families and community groups. Any reports of depression, other psychiatric disorders, treatment of said disorders, hospitalizations of relatives, and reports of suicide or self-injurious behavior must all be factored into the data collection. Use the Potential Vulnerabilities for Depression Sheet in the appendix to assess the patient’s family history. A copy is also provided for the patient in Chapter 4 of the workbook. Chapter 4 of this guide provides more information.

Psychological Screening The use of screening tools such as the BDI-II and the Hamilton Rating Scale for Depression (HAM-D) (Hamilton, 1980) are both easy to use and offer rapid screening specific for depression. It is advised that the clinician keep a stockpile of psychological testing measures so that they can be used as previously described.

Psychological Testing When possible, reports of psychological testing are useful as additional data to be used in the case conceptualization. If there are several reports that can track the psychological status of the individual over many years, they can be useful at tracing patterns and patient experiences, along with recommendations made at the time of the testing. If previous testing is not available, we would question the need for a full psychological evaluation.

21

The diagnostic question can usually be answered by the methods just discussed rather than in a single testing session.

The Clinical Interview It is in the clinical interview that the therapist’s style, experience, and expertise will be valuable. By using the interview as a snapshot or microcosm of the patient’s world, the patient’s response speed, latency, response style, and mode of response to the interviewer all offer an opportunity for data gathering. We find that the use of information forms given to the patient prior to the interview and reviewed by the clinician offer a structure to the interview that is very important.

Case Conceptualization To develop accurate assessment plans, case conceptualizations, and, ultimately, effective treatment plans, cognitive behavioral therapists must carefully assess the features, context, and manner in which an individual’s difficulties develop (Thorpe & Olson, 1997). Persons (1989) and Needleman (1999) offer clinically useful models. The case conceptualization is a template for understanding individuals. The conceptualization can be tested. Does the conceptualization account for the patient’s past behaviors, explain the patient’s present behaviors, and predicts the individual’s future behavior (Needleman, 1999). The formulation is directly linked to the assessment. As a higher order process, case conceptualization firmly rests upon the careful collection, evaluation, and interpretation of valid and reliable behavioral assessment data. The quality of behavioral assessment data directly affects the quality of the formulation. A poorly conceived and implemented behavioral assessment plan could misinform the conceptualization process and ultimately undermine treatment. The assessment data fuel the case conceptualization process by providing clinically relevant information that helps clinicians and the patients understand their problems more fully. These data are integrated and synthesized with other relevant information about the individual and

22

form a solid foundation for the selection of specific treatment protocols. Finally, this information is helpful in predicting barriers to treatment.

Treatment Planning Treatment planning and implementation are critical to successful cognitive behavioral therapy. Both are linked to the therapist’s ability to generate clinical hypotheses and develop, refine, and tailor treatment to the individual’s needs. Behavioral assessment helps the clinician formulate case-specific treatment plans (Needleman, 1999; Persons, 1989) that are of direct relevance to the individual’s treatment. Assessment enables the clinician to reduce target problems into observable and measurable units. It also informs the treatment process in an ongoing manner. For example, baseline data provide the clinician with important information about the state of the individual’s problem before an intervention has been made. During the course of treatment the clinician expects that if the treatment is appropriate, the critical aspects of the problem that change will occur in the desired direction.

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Chapter 3

Socialization

(Corresponds to chapters 1–3 of the workbook)

Therapist Note ■

On average, it will take 1–2 sessions to complete this module.

■

Materials Needed ■

BEAST Questionnaire

■

Treatment Consent Form

■

Tracking of Mood (TOM) Form

■

Establish rapport and provide brief overview of CBT

■

Describe the TTB program

■

Address issues of medication

■

Anticipate questions about therapy during socialization period

■

Assign homework

Outline

Building Rapport The socialization to the language, philosophy, theory, purposes, and techniques of CBT begin during the assessment and in the first few

25

therapy sessions. The identification of target complaints and their translation to relevant goals is an important aspect of the initial phase of therapy. Patients are more likely to be better collaborators in the therapeutic endeavor and to participate if they understand the concepts and rationale of therapy in general and the specific methods introduced by the therapist (Kazantsis, Deane, Ronan, & L’Abate, 2005.) The socialization and rapport building often begin at the point in time the therapist talks to the patient regarding setting an appointment for evaluation. Introducing the concept of collaboration is important to do at the beginning of treatment. It is as important as finding out the patient’s history and therapy goals (Beck, Rush, Shaw, & Emery, 1979).

How Does the Therapist Present Himself/Herself? First impressions are important in almost any relationship and especially so in psychotherapy. Empathy, warmth, acceptance, being genuine, eye contact, compassion, and a positive attitude are all potential qualities that lead to relationship building. Also, having a sense of what is comfortable for the patient will help the therapist titrate components of the above qualities in reasonable proportions. Some patients are hungry for warm fuzzy welcomes. At the other extreme, too much engagement may cause another type of patient to run away from the therapy relationship. Aaron T. Beck addressed this continuum labeling the two poles as sociotropy and autonomy. The sociotropic patient is one who wants his therapist to be someone he can feel comfortable with similar to a good and trusted friend. This person may seek more reassurance in the process of therapy for depression (Beck, 1983; Beck, Robbins, Taylor, & Baker, 2001). The autonomous patients are more likely to be businesslike or perfunctory in their approach to treatment. They may not have much interest in the person of the therapist and may emphasize their interest in competence and results. Most people are at neither extreme, but there are some who may lean more one way than the other. One way of looking at the difference is in terms of the therapeutic bond and the therapeutic alliance. The bond relates to the relationship between therapist and patient. The alliance relates to the goals and purposes of

26

therapy. Being sensitive to the patient’s style can make the difference in the establishment of rapport and the potential for positive results in treatment. The autonomous leaning patient may be uncomfortable with personal chat and what might be perceived as overly solicitous friendliness and ingratiation.

Providing Initial Information on CBT and Your Credentials: Using the Internet It is helpful if you can supply your patient a brief outline of how you conduct cognitive therapy on or before the first visit. A brief outline or introductory pamphlet regarding CBT is useful. Such information can also be published on a Web site that represents the therapists or therapist’s group. Over the past 10 years, the utility of Web sites for psychologists in practice has become more necessary since many people seek their treatment by searching the Internet (Maheu, 2003; Maheu & Gordon, 2000). Useful components of your Web site may include a brief explanation of cognitive therapy. Good introductory descriptions of cognitive therapy that are clear with minimal professional jargon can be found at established Web sites including the following: ■

http://cognitiveatlanta.com/cognitive_therapy.htm

■

http://www.academyofct.org

■

http://www.artcbt.com

Putting information such as a brief resume or curriculum vitae can also lead patients to have more confidence in their chosen or assigned therapist. Patients are typically interested in credentials such as certification and training as a cognitive therapist from a reputable organization such as the Beck Institute (Philadelphia), Atlanta Center for Cognitive Therapy (Atlanta), or The Freeman Institute (Fort Wayne). Certification through the Academy of Cognitive Therapy is an important credential. For psychologists interested in attaining diplomate status, the American Board of Professional Psychology (ABPP) and one of its constituent boards the American Board of Cognitive and Behavioral Therapy (ABCT) offers certification in Cognitive and Behavioral Therapy.

27

Program Overview The metaphor of the depression “beast” is understood as a whole and the sum of its parts. As a whole, the patient can visualize depression as an unwanted creature of experience and mood. It can be a negative monster when it is out of sorts and out of balance. It holds the future hostage and can be mean and cruel to perceptions of self, others, and the world. Depression as a beast is palpable and can be conceived as a state of consciousness that has a physical and emotional analogy. When socializing the patient to the components of the program, it may help to write the BEAST acronym on a dry erase board or flipchart, or distribute a handout to the patient. The next step is an explanation and narrative to help the patient understand how each component of the TTB program relates to one another. Define depression as a combination of many aspects and issues. Re-balance the depression BEAST and mood and the quality of life improve. In many ways, therapy can be explained as promoting ecology of personal experience, balancing behavior, feelings, and reason. Just as an environmentalist might strive to keep things in balance in nature, cognitive therapy attempts to bring balance to the personal environment. The idea of taming the BEAST can be a powerful metaphor for the patient who feels lost in the pain of his depression. The following sections provide instruction for introducing the patient to the individual components of the program.

Biology Biology or biochemistry can be explained in a variety of dimensions. Many patients are already taking medication or at least are aware that medication to treat depression exists. If the patient is taking medications or has seen others improve with the use of medication, then asking the patient to consider this as an example of how biochemistry affects mood can have an immediate impact. There are other examples of how biochemistry and emotion are related. Ask the patient to consider the example of a person who has not eaten for several hours or more. What kind of emotions may emerge? Irritability? Difficulty

28

concentrating? Physical illnesses of all sorts can be used as examples of how body condition affects mood. Ask the patient to think about his mood when he has a headache, or a virus, or a cold. Such initial discussion of the relationship between experience, mood, and body/biology invite the patient to see connections. You may also want to explain that biology is not the final word on what can impact mood. The idea of a “biological depression” would be true in almost every mood disorder, but it is a limited view that is not adequate unless it takes into account the other components of BEAST.

Emotion Emotion is often the focal point of what brings the patient to treatment. How one feels identifies an aspect of experience that is expressed in a word or two. Although cognitive therapy provides methods to help lessen the depression and dysphoria, it is not necessarily an entry point. In other words, we do not try to have the patient emote more or less, but instead try to restructure other components of the BEAST to help change the entire system of experience. Our entry points are cognitive and behavioral, represented by the A (activity) and the T (thinking) of the acronym. The cognitive therapist does not usually work with a patient to emote more to change emotion, but does not discourage the expression and understanding of mood. Mood change is measured in this therapy after restructuring thought and behavior. Improvement is generally defined as a lowering of distress levels as mood is monitored with evaluation tools such as the depression inventory that looks at the symptoms of depression that are checked for levels of intensity.

Action Action, activity, and behavior are entry points of cognitive therapy that are crucial for explaining the socialization process. Ask the patient if he has ever felt like staying in bed all day upon experiencing a depressed mood state in the morning. Then, find out if the patient has ever actually not gotten up and remained in bed all day. If so, ask the patient if

29

doing that helped his mood. The likely answer is no, making the next question, “why not?” Personalizing any explanation of the relationship between mood and activity helps engage the patient in the utility of behavioral change and mood improvement. Activity is often the first assignment in CBT. There is significant empirical evidence to support the utility of exercise (Brosse, 2002) to improve mood state and a sense of well-being (Fox, 2007). It is a good idea to introduce the assignment of an Activity Schedule (see Chapter 6) in the first session. Also, you are advised to assess the level of exercise the patient engages in or used to engage in. If the patient used to exercise and stopped since he has been feeling depressed, then this might also produce direct evidence that the cessation of exercise may be related to lowered mood as well as the reverse—that lower mood led to stopping activity. You might also ask the patient if he knows of any chemical changes that occur when a person is active. Many people are aware of the production of endorphins that come from exercise as a result of popular press coverage of this phenomenon (Yeung, 1996).

Situation Define situation to the patient as the circumstances or environment that one is in when distressing emotion is experienced. It is usually not an entry point for therapy. Instead it is observational and objective. This therapy looks for the factors that may help explain what led to a depressive episode. These factors or “triggers” may be historical such as stress, trauma, family issues, interpersonal events, and so forth. In this therapy, you will work with the patient to identify the specific situations or environments that are associated with his depression. This part of the socialization process is part of the guided empiricism and discovery that characterizes the cognitive model of treatment (Bennett-Levy & Bland, 2005).

Thoughts Thought is another term for cognitive experience. How we feel is often related to how we interpret our situation, self, and the future (the 30

cognitive triad). Explain to the patient that it does not matter which comes first, the feeling or the thought. If you change one component of the BEAST, you can potentially change the system of experience. Eventually, you will introduce thought recording as a way for the patient to distance himself from his feelings and thoughts. This will potentially give the patient the degree of objectivity he needs to restructure his thinking and test to see if what he did helps improve mood. You can help the patient better understand the interrelationship of each of the program components just described by providing him with an example that he can relate to. Here is a sample of a way to engage the patient in connecting the components of the BEAST. Let’s use an example that involves your imagination to help you to see how the components of the BEAST are connected. I want you to think of yourself at home in bed at night. You are tired; you are ready to go to sleep. The temperature is just right, your pillow is comfortable, it is quiet, and you are about to drift off. At this point, you hear a noise. I am going to give you your thought and I want you to tell me what your emotion and action would be if you had this thought. The thought is “That noise is a robber trying to break into my house and he is going to steal from me and hurt me and my family.” If that was your thought, what would your emotion be and what would you do? [Typically, the answer is a description of fear along with attempting to do something to protect self and family]. If the patient states that he wouldn’t necessarily jump to such a conclusion, let him know that for the sake of the example he has to accept that this is his thought and that he believes it at the moment. When the patient describes the fear and the activation, you then have the opportunity to ask about biochemistry. Is there any kind of biological change that occurs in your body when you interpret the situation as dangerous? Usually the patient will suggest that there might be a rush of adrenaline and that it stimulates him to become wide-awake and vigilant. From there, you can then help the patient connect the dots of the BEAST: The situation of a dark room and a noise, the thought of a threat, the emotion of fear, the biochemical body changes of adrenaline, and the action of making a call and/or checking the house or getting a weapon.

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I want you to go back to the beginning of our example. You are in bed, comfortable and ready to fall asleep. You hear a noise and this time you think this: “The weather report said it was going to rain and that is exactly what is happening. The grass needs the water and I closed the windows earlier.” If you had that thought, what would your emotion be and how would you act next? [It is likely that the patient will say something such as he likes the rain at night because it helps him sleep and that is what he would likely do.] In this example, the situation is a noise, the thought is that the noise is nothing but the rain, the emotion is calmness, and the action is to go to sleep with all the biochemical changes in the brain that allow a person to drift off. Next you can ask the question, “Why would one person conclude that there was danger and another person view the noise as benign?” Other Socratic questions you might ask to get the patient thinking might include, “Do you think anything about past experiences may influence how a person interprets the sound?” “If there was a notice put in your mailbox that there was a neighborhood watch due to recent criminal activity, how would that affect how you interpret the sound?” Helping the patient see how internal and external processing can affect mood by having an impact on interpretation and emotion can be done without being pedantic or dry. Eliciting responses that personalize the concepts help get the patient intrigued with the model and motivated to engage in therapy for change.

The BEAST Questionnaire The BEAST Questionnaire is a simple set of 25 yes or no items that can help the patient consider what components of his experience are emphasized in his worldview. It can also act as a decision-making method in the collaborative process by giving an indication where the patient is more likely to be experiencing problems. If one or more aspects of the BEAST Questionnaire has more “yes” answers than others, use this information as an opening to ask more questions about those aspects and get the patient to elaborate on those components of his experience. It may

32

also be useful to get the patient to look at that section of the patient workbook in the effort to understand its relationship to maintaining his depression, as well as to highlight techniques to promote change in those areas of greater concern. A copy of the BEAST Questionnaire is provided for the patient in Chapter 2 of the workbook. A copy for your use is provided in the appendix.

Discussion of Medication Finding out if the patient is on medication or if he wants medication for his mood problems is expected in the treatment of depression. This is further explained in Chapter 4. If the patient asks if medication is necessary, you may find yourself in delicate territory. If you are not a medical doctor or prescribing professional, it is important not to endorse nor deny the utility of antidepressant medication, but to let the patient consult with a health care practitioner. You may wish to give the patient the option of trying the TTB program before making a decision about medication. However, if there is medical opinion that the patient should be on antidepressants, let the patient know that the combination of medication and CBT can be mutually enhancing and that one form of therapy does not preclude the other.

Anticipating Questions About Therapy During Socialization The patient who comes to therapy is suffering. Many times patients form lasting impressions by how questions are answered in the beginning of therapy. Perfunctory processing of the patient’s evaluation should be avoided in almost all cases. Whether the patient asks for reassurance or not, he is likely looking for reasons to feel confident in the therapy. The combination of feeling hopeless and wanting help is comparable to driving a car with one foot on the brake and the other on the gas. Answering questions clearly and honestly can help the patient start to engage in the therapy, and unsatisfactory answers may lead the therapy to stop right at the beginning. It is not unusual for a patient entering

33

psychotherapy to expect that it will somehow magically remove his suffering. An expectation of lessening of symptoms is realistic, and when expectations are equivalent with outcome, satisfaction is enhanced. However, it is unrealistic for patients to expect that their future will be free of sadness, disappointment, or temporary periods of dysphoria. Although finding evidence for psychotherapeutic cures has been an ideal goal of therapists from the beginning of organized psychotherapy, research has not demonstrated that a “cure” exists. There is, however, ample empirical support for CBT in enhancing coping ability and modifying and altering thought patterns, feelings, and behaviors. By definition, CBT is a “coping” model rather than a “cure” model of therapy.

Socialization and Treatment Consent The initial phase of treatment should include socialization or education to the model in which unrealistic expectations are addressed and modified with respect to the search for a “cure.” It is better this not be done in a manner that discourages your patient from hoping for relief, which can be an important motivation to engage in the work of therapy. You can explain to your patient that when he engages actively in the TTB, doing homework between sessions, he can realistically expect significant therapeutic gains as he progresses through treatment. In this way the patient’s unrealistic expectation of finding a cure can be gradually replaced with the satisfaction in realizing more realistic therapeutic gains and enhanced ability in experiencing pleasure in his daily life. You can help your patient to engage in this process by conceptualizing the period of formal psychotherapy as a structured time in which he can learn to become his own psychotherapist. Therefore, during the initial phase of therapy as you socialize your patient to the TTB model with specific attention to termination, it is important to discuss your philosophy of treatment, policies, specific areas of competence, and how you work therapeutically. At this time you can discuss the necessity for the inclusion of relapse prevention phase prior to termination. It is common for patients to ask directly how long the therapy will take. However, it is your ethical responsibility to initiate a discussion of the conditions of treatment, what your

34

patient can expect from you, and what you expect from the patient with respect to the collaborative “work” of psychotherapy. These parameters are referred to as the “therapeutic contract” and provide the structure necessary to effective psychotherapy. To help assure a successful termination, this discussion should include estimated length of therapy, criteria for termination of formal treatment, and statements regarding the possibility of unplanned situations. These practice policies are best presented in writing in a Treatment Consent Form that the patient signs to assure his understanding. It defines the conditions of treatment, your therapeutic and practical limits, payment agreement, expectation of compliance with attending sessions, doing homework, and conditions under which you may terminate treatment. The manner in which you ethically and compassionately enforce the limits of the treatment contract is sometimes referred to as the “treatment frame” and is necessary for successful psychotherapy and specifically, successful termination. Thus, termination is forecasted in the initial phase of treatment in which the therapist and patient set forth the goals of the therapy, target specific problems, and agree upon a treatment plan that includes a course of action, an estimated number of sessions, and a plan for termination. This model of successful termination remains an integral part of the entire therapeutic process and requires ongoing dialog and possible revisions in the treatment plan as well as the anticipated end of therapy. The model is consistent with “prospective” termination by Davis (Freeman, Felgoise, & Davis, 2008), characterized by the ongoing quality of the interaction of the therapist and patient regarding the ending of therapy, and determined by three elements: ■

Direct communication about reasons for termination

■

Opportunity to express feelings, check perceptions, and assess satisfaction with therapy and therapist, and

■

A clear disposition decision concerning any ongoing or potential future needs. (Freeman et al., 2008).

A sample Treatment Consent Form is shown on the following page. You may photocopy it from the book and distribute to your patients, or use it as a model for creating your own consent form.

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Treatment Consent Form I have discussed treatment with my therapist and I agree to the following: 1. I agree to attend scheduled sessions regularly and provide at least 48 hours notice of cancellation or need to reschedule, except for true emergencies. 2. I understand that a pattern of repeated failure to keep appointments may result in termination of therapy. (i.e., I fail to keep three continuous appointments or do not respond to my therapist’s attempt to reschedule missed appointments.) and agree to comply with the terms of the financial agreement. 3. I agree to a fee of I understand that if I fail to comply with these terms, services may be terminated and referrals made to other clinicians. 4. I agree to work with my therapist to the best of my ability and immediately discuss openly any issues that interfere with the treatment. (e.g., worsening of symptoms, self-harming thoughts or urges, dissatisfactions with therapist or treatment, situations that prevent me from following the treatment plan, effects and/or side effects of any medication I may be taking, or factors that might preclude continuing with treatment.) 5. I understand that in situations of eminent risk of harm to myself or others, my therapist may elect to divulge information without my specific consent, only to whom and to the extent that it is deemed necessary for immediate safety. 6. I understand that only in the event of an emergency involving my therapist, during the course of treatment or after it has concluded, that his or her clinical designee may need to manage my clinical records according to sound clinical practice and ethical guidelines.

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Signature of Patient

Date

Signature of Therapist

Date

Treatment Progress and Tracking of Mood This will also be a good time to discuss that progress is usually uneven and it is to be expected that the general progress toward goals is likely to be punctuated with plateaus and even periods of temporary lower moods and re-emergence of targeted problems. By anticipating these periods you can assist your patient in viewing them as useful information necessary to the ongoing re-evaluation of the treatment plan. To provide objective measures of your patient’s progress throughout psychotherapy, the Tracking of Mood (TOM) Form is useful (see Chapter 2 on assessment). Scores from the Beck Depression Inventory-II and Hopeless Scale and subjective self-reports of pleasure and satisfaction from the Activity Schedule provide good summary information, and scores can be entered on a table on a session-by-session basis. Additional scores can be entered in the row marked “other”, such as scores from the Hopelessness Scale or a rating of procrastination. Vulnerability factors such as pain may be abbreviated and numerical sums entered. If your patient is more visually oriented the scores can be plotted on a graph as well. The TOM can be used throughout the course of treatment to provide evidence of progress and continually re-evaluate and modify the treatment plan. In the relapse prevention phase, the TOM is useful for identifying specific target areas for creating a relapse prevention plan. It can also be used in the termination phase to determine the patient’s readiness to end treatment. The topic of termination is integrated throughout the course of treatment and revised and tailored to the individual patient as treatment progresses. The actual termination phase overlaps with the relapse prevention phase. During the termination phase, therapeutic techniques previously learned during the course of treatment will be further reinforced and therapeutic progress consolidated. Since mood states are often temporary, your patients will likely have to deal with brief periods of high stress, dysphoria, and inertia during treatment as well as in the future. During these times, the patient will have the opportunity to use the therapeutic techniques he learned in treatment thus decreasing the possibility of episodes of clinical depression in the future. In essence, your patient becomes autonomous in his ability to use cognitive

37

therapy concepts. Laying the groundwork in the beginning of therapy allows for the likelihood of successful treatment and eventual transition to improved functioning for your patient.

Homework The first homework assignment is best given after the initial contact and evaluation. Homework may include writing down goals for therapy, selfmonitoring, cognitive restructuring, and so on. If the patient has been in previous therapies that were not CBT-based, the idea of at-home assignments may be foreign to him. Explain to the patient that homework is an essential component of treatment associated with successful outcomes. It is usually a mistake to assume that a patient will complete an assignment only because of the authority of the therapist. This is one of the first chances to introduce collaboration. The patient role is to collect the data and bring it back to the therapy session. As the therapist, your role is to offer the patient guidance in understanding what is associated with his mood problems and in finding ways to change the patient’s patterns of behavior and thinking in order to improve mood (Kazantsis et al., 2005) (Persons, Burns, & Perloff, 1988). Another good first assignment is the Activity Schedule (see Chapter 6). This provides both patient and therapist a baseline that is much more useful than only assessing how the patient evaluates his week on the day of his appointment. It also provides an introduction to the empiricism of the therapy approach. Engagement in assignments is collaborative. Both therapist and patient are to agree on assignments and the utility of their rationale. This gives the patient a sense of control and importance that make progress more likely. Suggest to the patient that he get a folder or notebook to keep his assignments in chronological order. This emphasizes the importance of collecting and reviewing data as well as determining which techniques have worked and which ones have not. It also provides the patient with a valuable review of how he used effective methods in case he experiences setbacks after therapy ends.

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Chapter 4

Biology

(Corresponds to chapter 4 of the workbook)

Therapist Note

The number of sessions required to complete this module is determined by the therapist according to the specific needs of the individual patient. ■ ■

Materials Needed ■

Tracking of Mood (TOM) Form

■

Medical/Physical Information Sheet

■

Food Log

■

Medication Log

■

Potential Vulnerabilities for Depression Sheet

■

Review biology and depression

■

Review lifestyle and depression

■

Review medical conditions and depression

■

Review biological treatments of depression

■

Assign homework

Outline

39

Therapist Note

Throughout this chapter, the term “health care provider” or “health care practitioner” is used to refer to those professionals who prescribe medication that will be part of a comprehensive treatment for a number of psychological problems. These providers include family physicians, psychiatrists, advanced practice psychiatric nurses, physician assistants, and psychologists with prescription privileges. ■

Although other health care providers have prescription privileges within their scope of practice (e.g., dentists or poediatrists), the prescription of medication for psychological problems like depression or anxiety should, ideally, be done by a health care prescriber who has had specialized training and experience with the broad range of current medications available for treating psychological disorders. This is because the combination of medications and dosages can impact on mood, thoughts, and behavior in both positive and negative ways. ■

Biology and Depression Depression has a significant physical dimension just as physical problems or medical illness may have a significant affective component. Historically, both biological and psychosocial causes have been proposed, even to the point of considering “biological” (endogenous) and “reactive” depression as two separate conditions. In the current classification system, which has been in use since 1980, major depressive disorder is considered along the biological–psychosocial continuum. There are those who are on the far end on the biological end of the continuum, considered to have significant inheritability factors. However, in most instances of depression this is not the case. The biopsychosocial model of depression describes the interdependence of the biological, psychological, and social causes of depression. The diathesis-stress model includes the interrelationship among these potential causes of depression as well as the degree to which people may be vulnerable to react to those causes. In the latter conceptualization, people have varying degrees of vulnerability or predisposition for developing depression. These vulnerabilities are referred to as “diatheses” and

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include biological and genetic factors. Some people may have more vulnerability or predisposition for developing depression than others, but this collective propensity alone may not be enough to cause depressive illness or a depressive episode. The added effect of stressful life events, situational, psychological or biological, prompts the onset of a depressive episode. Various protective factors can act as interference to the inevitability of depression or ameliorate the severity of symptoms once they are present. This protection includes the notion of resilience, which has received a great deal of attention in recent years. Regardless of the proportionate relationship of biological-genetic factors involved, CBT and in particular the TTB can be effective. Also, when relapse prevention is included as a component of the treatment, further protection can be provided against future episodes.

Physical Manifestations of Depression Every body system can be affected by depression and can, in turn, contribute to it. A depressed person may experience vague body aches, muscle weakness or joint pain (muscular-skeletal system), appetite disturbances, abdominal pain, bowel problems (digestive system), shakiness, tingling, or dizziness (neurological system), sexual changes or dysfunction (reproductive system), urinary changes such as needing to urinate more frequently (genital-urinary system), or sweating more than usual (dermal system or skin). The usual physical manifestations are termed vegetative signs of depression and include pain, low energy, decreased or increased appetite, disturbances in sleep, and sexual dysfunction. A simple review of the biological aspects of depression can be introduced to your patient in a variety of ways. An initial general discussion of the relationship between experience, mood, and body/biology can progress to encouraging the patient to appreciate such relationships in her own experience. You can ask the patient to consider the very simple example of how she feels when she has not eaten for several hours or more. What emotions may emerge? Does she experience irritability or have difficulty concentrating?

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Many patients are already taking medication and most are aware that medication to treat depression exists. If the patient is taking medications or has seen others improve with the use of medication, this can be used an example of how biochemistry can effect mood. Physical illnesses of all sorts can be used as examples of how body condition affects mood. Ask the patient to think about her mood when she has a serious illness, or even a headache, virus, or a cold. Ask her to list all the medications she is taking on the Medical/Physical Information Sheet in Chapter 4 of the workbook (see also Chapter 2 in this guide on assessment). You can then complete the Medications Log (this should be done during the initial session). Request that the patient tell you when adjustments of dosage or changes are made, and if and when medication is discontinued. Ask the patient to report changes in symptoms, dosages, and side effects. When these changes are made you can update the patient’s Medications Log. This is very important as you and your patient evaluate symptoms during the course of treatment. A copy of the Medications Log is provided in the appendix, as well as in Chapter 4 of the workbook. Some patients may come into psychotherapy saying things like “I have a “chemical imbalance so I don’t think psychotherapy will help” or “I have bipolar disorder because I have mood swings; sometimes I am really sad and sometimes I am really happy.” Patients often do not understand what mood swings actually are and need education in this regard. Some may hear a discussion of biological factors or possible genetic predispositions as justification to divest themselves of all personal responsibility of how they may maintain their depression or manage it once it is present. Others may interpret your discussion of potential biological factors in depression as implying that there is nothing they can do. By considering herself a victim of her biology, of something she cannot change, the patient forecloses the opportunity to discover important ways she can relieve herself of her depression. All of these unfortunate misinterpretations are far from the truth. In contrast, you can appreciate the part your patient’s own unique biology plays in her depression while at the same time encourage a sense of personal responsibility in dealing with it. For example, in the case of someone with a strong family history of bipolar disorder or a serious medical illness, you can be empathetic without joining the patient in perceiving herself as a victim in the same way you

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might with other people who have other challenging realities to face in their lives. It is important that special attention to biological factors be included in the assessment and treatment of your patient. The Medical/Physical Information Sheet and the Potential Vulnerabilities for Depression Sheet (see Chapter 2 on assessment) can assist you and your patient in understanding possible biological aspects of her depression and identifying her specific vulnerabilities to depression. This can be useful in formulating the treatment plan as well as the relapse prevention plan and in assisting the patient in taking personal responsibility of her medical and self-care, with respect to overall mental and physical well-being. It is important to emphasize the relationship of proper diet, regular exercise, and sufficient sleep to the patient. Further, encourage her to respect herself and her body by engaging in health-promoting habits. Your treatment plan may need to include specific attention to cultivating these habits. Finally, you can explain that biology is not the final word on what can impact mood. The idea of a “biological depression” is true to a certain extent, in almost every mood disorder. However, to assume it is the cause or only aspect in most cases, or even the primary aspect represents a limited view that is inadequate. The TTB promotes a holistic viewpoint and takes into account all other components of depression as well, as reflected in the acronym BEAST. The following discussion is provided for you to understand some of the biological aspects of depression and is not meant to suggest that all the information needs to be provided to the patient. You will need to be selective in what you decide to provide your patient, depending on your judgment of what is relevant and what could be helpful.

Neurophysiology and Depression Depression is experienced biologically as a function of the mind-brain relationship. Therefore, at least a cursory understanding of the neurophysiology of brain functioning is needed. Very simply, the brain is an organ made up of millions of cells (neurons) which contain and require

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important chemicals (neurotransmitters) in order to function. Neurons are electrically charged cells. Electrical charges are affected by the neurotransmitters and communicate impulses which affect movement, thought, sound, sensation, and vision. We take this complex system for granted each day. That is, until something does not work quite right. Research has shown that the specific neurotransmitters related to depression include serotonin, norepinephrine, dopamine, and sometimes gamma-aminobutyric acid (GABA). If there is too little or too much of a particular neurotransmitter in the brain, communication between neurons is affected. Antidepressant medication is used to target these neurotransmitters in order to change or regulate mood. However, recent research has shown that these neurotransmitters are changed by other factors as well. Serotonin is involved in regulating many important physiological functions, including sleep, aggression, eating, sexual behavior, and mood. Norepinephrine (NE), known also as noradrenaline, is identified as the stress neurochemical and is released in the fight-or-flight response or when extra energy is needed in order to increase heart rate and to release glucose stores from the liver and fat for the purpose of increased muscle readiness. In the brain, NE contributes to the ability to focus and sustain alertness. Dopamine, along with serotonin plays an important role in the ability to sense pleasure and to regulate drives. Low dopamine levels may be related to the inability to focus and derive pleasure. Gamma-aminobutyric acid (GABA) is an important inhibitory neurotransmitter in the nervous system. Basically, GABA suppresses neuronal electrical activity which may prevent the firing of the neurons. Such activity occurs with the use of anticonvulsants or in the use of alcohol, opiates, or anxiolytics. In depression there is altered brain activity. Some parts of the brain show decreased activation, and other parts show increased activation. Neuroimaging (PET scans) shows that depressed people have less activity in the prefrontal cortex of the brain and more activity in the limbic system. The prefrontal cortex is associated with regulation of emotions, more specifically in helping to inhibit negative emotions generated by the

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limbic system. Thus, if the prefrontal cortex is less active, negative emotions (such as depressed mood) may be experienced and/or expressed more frequently and more intensely. Also, the hippocampus is vulnerable to the effects of stress and in severely depressed people its volume is decreased, possibly as a result of the effect of higher levels of glucocorticoids. These three regions of the brain are involved in the exacerbations of depression and are all targets of stress hormones. The preceding oversimplified discussion might be misconstrued to mean one’s biology causes depression. This is not the case for most people who are depressed. Even though the neurophysiological aspect of the experience of depression is undisputed, the once accepted dogma that what is hardwired in the adult brain cannot be changed has been challenged and refuted (Schwartz & Begley, 2002). Animal studies paved the way to demonstrate this empirically and then later studies involving human beings provided further empirical support. Recent advances in neurodiagnostic techniques have further advanced understanding of the mind-brain relationship. Examples of these non-invasive techniques are PET scans, and functional MRIs (fMRI) have allowed neuroscientists to specifically identify those regions of the brain that are active during, or related to, various mental activities and emotional states. In some studies in which fMRIs are compared over time, results suggest that mental activity can and does act directly back on the brain as well as being the result of it. Neuroscientists and clinicians refer to the physical/physiological processes affecting the mental processes as “bottom up” functioning and mental activity affecting the physical/physiological processes as “top down” functioning. The latter effect to and in the brain is referred to as “neuroplasticity.” Neuroplasticity has great clinical relevance in CBT, which focuses on “retraining” thinking patterns. Concerning the effects of CBT on brain functioning, Schwartz and his colleagues (Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996) showed on PET scans that after CBT treatment of 18 OCD patients, activity in the orbital frontal cortex of 12 patients had fallen dramatically. “This was the first study to show that CBT has the power to systematically change faulty brain chemistry in a well-identified brain circuit” (Schwartz & Begley, 2002). The research of Segal (1994) and his colleagues (Teasdale et al., 2000), while somewhat different in focus, also suggests a “top-down” effect. Mayberg and her colleagues (Goldapple

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et al., 2004; Mayberg et al., 2002) continue to study brain functioning in depression in relationship to psychotherapy as well as new surgical interventions called deep brain stimulation.

Neuroendocrine System and Depression The nervous system is the gatekeeper of the endocrine system. The control center for all endocrine functioning is in the pituitary gland, located within the brain. This system is inextricably linked to the hypothalamic, limbic, and reticular activating systems. These systems control and regulate many different body functions such as blood pressure, appetite, immune responses, body temperature, maternal behavior, and body rhythms pertaining to circadian and seasonal rhythms. Circadian refers to the 24-hour cycle of the body, which is determined by the amount of light that the hypothalamus senses in a day–night cycle. Both brain wave activity and hormone production are integrated into this cycle and when the circadian rhythm is disturbed, mood disturbances can also result. Similar to circadian rhythms, seasonal rhythms are determined by the amount of daylight within a given season, and can also impact mood, and specifically in the case of seasonal affective disorder (SAD). The adrenal glands, located near the kidneys, produce hormones that are involved in metabolism, immune function, and the stress response. These hormonal secretions (cortisol) are regulated by the pituitary gland. Individuals who have low levels of cortisol and adrenaline generally feel exhausted and sick (Gaab et al., 2002; Wessely et al., 1996). Recent and ongoing research has shown relationships among cortisol, psychosocial stress (a well-known precipitant of depressive episodes), innate immune response activation, and depression. Specifically, patients with major depression have been found to exhibit evidence of an activated innate immune response (increased biomarkers of inflammation, including innate immune cytokines, acute-phase proteins, chemokines, and adhesion molecules) (Miller & Raison, 2008). Major depression has also been shown in numerous studies to be associated with plasma concentrations of cortisol (Raison et al., 2003) and of interleukin-6 (IL-6) (Raison, Capuron, & Miller, 2006) and both have

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been associated with chronic life stress. Increasing research shows that chronic life stress increases plasma concentrations of IL-6 and that even slightly increased levels can predict the development of some disease states (Kiecolt-Glaser et al., 2003; Perry et al., 2007; Pradhan et al., 2001; Ridker, 2000; Steptoe et al., 2007). Although the goal of some of this research has been in the service of developing psychotropic medications, the implications are more far-reaching. It would be a mistake to interpret the results of this research as causal; that is, to suggest that cortisol causes disease or depression, or vice versa. However, the implications of such interrelationships should not be ignored or dismissed. Along similar lines, data from a new study suggests that individuals who engage in meditation practices designed to specifically foster compassion may benefit by reductions in inflammatory and behavioral responses to stress, which in other studies have been linked to depression and a number of medical illnesses such as heart disease and diabetes. The mindtraining practice utilized a cognitive, analytic approach to challenge an individual’s unexamined thoughts and emotions toward other people, with the long-term goal of developing altruistic emotions and behavior toward self and others. Compassion meditation practice differs from other meditation practices that emphasize calming the mind, improving focused attention, or developing mindfulness. Sixty-one college students between the ages of 17 and 19 were randomly divided, comparing the effects of a 6-week compassion meditation training and a control group. The control group participated in a 6-week health discussion. Those in the compassion meditation group who also reported “high practice” showed greater reductions in inflammation and emotional distress in response to an experimental stressor. Further research is needed to conclusively show that it was in fact the compassion meditation that resulted in the reduced stress response (Raison et al., 2008). Future research will undoubtedly seek to further clarify these relationships and possible relationship between the immune system and depression.

Genetics and Depression Can depression be inherited? The answer is probably yes in some cases. However, the scientific pursuit to find a specific “depression”

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gene has gone unrealized. The results of the initial twin and adoption studies are somewhat debatable with respect to providing empirical support for a genetic basis of depression. Heritability continues to be a focus of intensive research and some promising, but modest findings are emerging with interest in specific regions of chromosomes (Craddock & Jones, 2001). Ongoing genetics research is being conducted in the NIMH Genetics Initiative on Bipolar Disorder (1997). Through genomic scans, genotyping was performed on 540 sets of DNA from 96 families with family members diagnosed with bipolar disorder. Longitudinal research is also being conducted among extended family units in communities that are relatively self-contained and receives little influence from outside environments with high incidence of bipolar disorder (Detera-Wadleigh et al., 1997, pp. 254–262; Edenberg et al., 1997). The influence of genetic predisposition as one factor in the development of mood problems cannot be studied in isolation because genetic and environmental factors are so interrelated. For example, parents may pass on to their offspring a genetic code for low mood and negative thinking. However, they also influence thinking, situations, and behavior in their children by their parenting skills and modeling through their own behavior. For most people, parents are the most significant influences for how to be in the world, with respect to actions, emotions, attitudes, and beliefs. There is no test to determine whether genetic inheritance is a major factor in your patient’s mood difficulties. Even geneticists use the language of predisposition, susceptibility, or risk rather than biological cause. The Medical/Physical Information Sheet and Potential Vulnerabilities for Depression Sheet (see Chapter 2 on assessment) can help you and your patient identify some potential genetic and other types of vulnerabilities that might need consideration in treatment and relapse prevention planning. Some people do have medical and family histories that suggest a genetic risk or vulnerability for the development of depression. Even though this may be so, it does not mean that they are destined to become depressed and the question remains for your patient, “What can I do about it in the present and in the future to lessen the possibility?” These, among others, are referred to as protective factors.

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Lifestyle and Depression Some of the best methods for dealing with the physical aspects of depression also make the most common sense. Lifestyle changes and developing physically healthy habits are important. Rather than passively waiting for the depression to lift and the physical manifestations to stop, you can assist your patient in expediting the recovery process by addressing the problems directly.

Mood and Diet Appetite disturbance with accompanying weight gain or loss is a common vegetative sign of depression. This may be related to the changes in physiology associated with depression or result from changes in eating habits due to depression, or a combination of both. Your patient may have trouble eating because she has abdominal pain or feels like her stomach is in a knot. She may experience a diminished desire for food or lack enjoyment in eating. Even highly spiced food may seem bland and uninteresting. As her depression worsened, she may not have realized she was missing meals. At the most severe level of depression, she may have needed to actually force herself to eat. Alternatively, a return of appetite may signal that her depression is lifting. It will be important to discuss with the patient the importance of eating for health rather than out of habit or only for enjoyment. In contrast, another patient may eat as a means of seeking comfort when she is miserable. She may eat out of habit or to seek enjoyment when little exists otherwise. She may not taste food in the same way she once did, fail to derive satisfaction from the subtle flavors of a well-prepared meal, and just keep eating mindlessly. If this is the case she may have gained a significant amount of weight, resulting in diminished self-esteem and sense of control. If the patient is taking antidepressant medications she may have side effects related to appetite and weight gain. Antidepressants that act on both dopamine and norepinephrine will increase dopamine and therefore decrease appetite. Medications that act on dopamine combined

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with serotonin such as with the atypical antipsychotics may enhance appetite, however. Sometimes nutritional deficiencies influence depression and sometimes depression contributes to nutritional problems. You can emphasize to the patient that her recovery from depression can be enhanced by healthy, nutritious eating. If she needs to be convinced by evidence, begin by asking her to recall how she has felt when she has missed meals, was hungry, or if she had overeaten, or binged on sweets. When energy is low the patient may not want to prepare healthy meals and instead eats “junk” foods that contain empty calories. It may be tempting for her to make poor food choices, such as consuming an overabundance of sugar or carbohydrates and not enough protein. A diet of cookies, potato chips, soda, and ice cream may be easy and available but it is a nutritional disaster. These types of foods may result in a quick drop in glucose levels in the blood with accompanying let-down feelings. Other habits that may result in mood difficulty may be skipping meals or eating erratically. Some depressed patients may skip meals as a result of disorganization, poor planning, or the pressure they put on themselves to accomplish more than is realistic. Some may simply not realize the importance of nutrition on physical health and mental well-being and need education. Low folate levels, vitamin B6 and B12, iron and thiamine deficiencies result in low energy, fatigue, low motivation, irritability, decreased concentration, insomnia, and perhaps contribute to depression in some people. Being underweight is a common cause of nutritional deficiency; however, surprisingly to many, being morbidly obese is also a common cause of nutritional deficiency. Review with the patient the problems identified on the Medical/Physical Information Sheet during the assessment procedures. If weight, appetite disturbance, or unhealthy eating habits seem to be a problem, a daily food log or eating log may be important to give as a homework assignment to further assess whether developing healthier eating habits might be an important therapeutic goal and to provide a baseline from which to plan interventions or actions. A blank Food Log is provided for the patient’s use in the corresponding workbook. Assisting the patient in developing healthy eating habits may be an important aspect to her overall recovery for several reasons. In addition

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to the physiological results, it can serve as an important area of developing mastery and self-care which in turn can enhance confidence, hope, and a sense of mastery in her life.

Sleep and Mood Sleep is so critical to the human body that researchers have even found that humans are actually likely to die faster from lack of sleep than from lack of food (Benca, 2001). Sleep disturbance is one of the major symptoms of depression; one of the accepted vegetative signs of depression. Studies have shown that depressed individuals may have difficulty going to sleep (initial insomnia), staying asleep (midphase insomnia), or may wake much earlier than they want or need to. Disrupted sleep can mean either too much sleep or too little sleep, insomnia as in initial, midphase, and early morning awakening, poor quality of sleep, or distressing dreams or nightmares. Sometimes having too little sleep on a regular basis triggers depression in an individual. Alternatively, some people stay in bed and sleep too much. This results in fatigue and lethargy and also is symptomatic of depression. The human body is meant to sleep an average of 8 hours for every 24-hour period. Although there are individual differences in the amount of sleep people need, generally those who sleep less than this on a regular basis are stressing their bodies. Eventually they may experience consequences in one way or another (Benca, 2001). For some, these consequences may be a psychological disorder such as depression and/or anxiety. For others, there may be impaired concentration and attention, and difficulties in organization and planning, all resulting in ineffective work or general diminished quality of life. Sleep disturbance may be manifested not only in the quantity of sleep, but the quality of sleep also, such as is the case in disturbed REM sleep. Be sure to fully assess the severity of the patient’s sleep disturbance in order to determine whether it is of recent origin, how severe it is, and what effect it is having on her life. Help the patient determine what environmental and dietary habits may be interfering with her regular restorative sleep. Changes may need to be implemented in order to improve amount and quality of sleep. The Activity Schedule (see Chapter 6) and Tracking of Mood (TOM) Form 51

may be helpful to your patient in establishing healthy sleep habits. As a first step you can encourage the patient to do the following.

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1.

Most important is to develop a regular routine by getting up and going to bed around the same time, even on weekends.

2.

Slowly shift into sleep mode by doing such things as dimming the lights an hour or more before going to bed, taking a warm bath, listening to calming music, engaging in relaxation exercises, and lowering the bedroom temperature (60–68◦ is optimal).

3.

Use the bedroom only for sleep (and intimacy). If the patient can’t fall asleep within an hour, or wakes in the night, suggest she get up and get out of the bedroom. She can read a book or do some other calming activity for another 1–1½ hours before trying to sleep again. If a person can’t fall asleep within the first hour, she most likely won’t be able to for at least 1–1½ hours. So staying in bed only causes frustration over not sleeping.

4.

Use the TOM Form to assist in determining possible reasons for difficulty sleeping such as having just eaten before bedtime and experiencing acid reflux.

5.

Avoid substances known to interfere with sleep such as caffeine (even in small doses) and alcohol. Although alcohol has an initial sleep inducing, sedative effect, as its effects subside, it also causes frequent and early awakening. Tobacco acts as a stimulant also. Advise the patient to speak to a health care practitioner about alternatives to medications that disrupt sleep or times she takes them.

6.

Eliminate or reduce stress as much as possible.

7.

Wake up without harsh-sounding alarms. Dawn simulation devices are much more effective at establishing a healthy sleep cycle and gently rousing the patient from sleep.

8.

Generally to avoid naps! If naps are absolutely necessary, make sure the patient only naps once a day for less than one-half hour.

9.

Exercise is one of the best defenses against insomnia and the ideal time for it is 4–6 hours prior to bedtime (O’Connor & Youngstedt, 1995).

10.

Increase light and dark signals by keeping the bedroom dark during sleep and getting bright light in the morning. Consider getting a specialized bright light box, especially if the patient has to get up before dawn.

11.

Try to avoid sleeping pills, herbal remedies, and supplemental melatonin.

Usually sleep improves without specific medical interventions. However, you need to assess your patient carefully with respect to sleep and remain aware that a medical evaluation and possible medical intervention may be needed in the most severe cases. It would be a mistake to allow the patient to become severely sleep-deprived. In addition to sleep disturbance as a symptom of depression, specific sleep disorders or certain medications can also disrupt sleep and contribute to depression. These include sleep apnea, circadian sleep disorders such as shift work sleep disorders, and restless leg syndromes. The Medical/Physical Information Sheet can be helpful in determining this. Be alert to the possibility of these as you assess your patient. If sleep disturbances, particularly primary insomnia, are a problem for your patient, you may wish to refer to Overcoming Insomnia: A CognitiveBehavioral Therapy Approach, Therapist Guide and Workbook (Edinger & Carney, 2008).

Sleep Apnea

Sleep apnea is a condition characterized by periods of paused breathing during sleep, either from lack of respiratory effort due to difficulties in the neurological feedback mechanism in central sleep apnea or in the much more common, obstructive sleep apnea (OSA). These numerous events result in EEG changes, decreased levels of circulating blood oxygen, and result in increased physical stress, elevated blood pressure, and prevents the patient from entering REM sleep, the restful and restorative stage of sleep. Symptoms of OSA include a pattern of waking up with gasps, snorts or startle responses, excessive perspiring during sleep, and a dry mouth upon awakening. Most often the patient herself is unaware of these events but is told of them by her partner. The patient herself

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may only be aware of excessive daytime sleepiness or decreased alertness, fatigue, difficulty concentrating, memory changes, irritability, and sometimes depression. Sleep apnea is diagnosed by an overnight “Sleep Study” often conducted by a sleep disorder specialist, usually a pulmonologist or a neurologist. You may need to refer patients for evaluation from time to time. The American Academy of Sleep Medicine maintains a Web site that provides useful referral information (www.assmnet.org). For mild cases of sleep apnea, lifestyle changes may be sufficient to reduce the frequency of events. These include avoiding alcohol and medications that relax the central nervous system (e.g., sedatives and muscle relaxants) before sleep, losing weight, and quitting smoking. Some people are helped simply by not sleeping on their backs. For most people with the condition, a continuous positive airway pressure (CPAP) machine is prescribed. A facemask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. Weight loss may relieve sleep apnea in some cases. In severe cases, OSA can contribute to life-threatening physical conditions, such as high blood pressure, stroke, and heart attack.

Circadian Rhythm Sleep Disturbances

Circadian rhythm is the name given to the “internal body clock” that regulates the (approximately) 24-hour cycle of biological processes in animals and plants. Patterns of brain wave activity, hormone production, cell regeneration, and other biological activities are linked to this 24-hour cycle. This circadian “clock” is located mainly in a group of cells located in the hypothalamus. Circadian rhythms are important in determining sleep patterns. Common circadian rhythm disorders include jet lag, shift work sleep disorder, and delayed sleep phase syndrome (such as those who fall asleep very late and have difficulty waking for their responsibilities). All of these have physiological manifestations and symptoms such as grogginess, irritability, concentration difficulty, appetite changes, memory difficulties, and mood disturbance. Some patients may need assistance in re-regulating their “clocks” which may be a focus of therapy and an element of the treatment plan. Gradual, incremental changes may be introduced into the patient’s sleep

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schedule over a period of weeks or even months. Sometimes the use of a specialized light is helpful.

Exercise and Mood One of the most common physical manifestations of depression is low energy. This might be apparent when your patient first awakens, feeling tired, or it may become apparent throughout the day. Some severely depressed people may have difficulty getting out of bed or staying out of bed during the day. Some of their fatigue may be attributed to sleep difficulties but not all of it. Passivity and inertia may be the prominent feature and is addressed in the activity module of the TTB program (The A of the BEAST). Regular exercise has shown to have positive effects on physical health in a variety of physical systems, including the cardiovascular and musculoskeletal systems of the body. Specifically regarding the effects of exercise and mood, there are several hypotheses; one of the first is the effect of increased beta-endorphins as described in the euphoric state of “runner’s high,” the various monoamine, hypotheses involving serotonin and dopamine (Dunn & Dishman, 1991; Nicoloff & Schwenk, 1995). This hypothesis has not been supported in replication studies. Studies have shown changes in levels of neurotransmitters in the brain, all of which results in reduced muscle tension, improved sleep, and reduced levels of the stress hormone cortisol (Acevedo & Ekkekakis, 2006). Regardless of the specific theories involved, it seems that most of the studies dealing with the psychological effects of exercise conclude that exercise does have a positive effect on depression. One early example is the study by Martinsen, Medhaus, and Sandvik (1985) involving a group of 43 clinically depressed men and women, their mood having been measured by the Beck Depression Inventory (BDI). All participated in a 9-week exercise program. Later, investigators were able to conclude on the basis of decreased BDI scores that exercise had improved their patient’s moods. The general conclusion from this experiment and others is that exercise, to some degree, can decrease depression in those diagnosed as depressed (Hassmen, Koivula, & Uutela, 2000). A meta-review of the available research (Phillips,

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Kiernan, & King, 2003) found that although there is need for more research with better methodology, the scientific literature is generally supportive of the beneficial effects of aerobic and non-aerobic exercise on depression in clinically and non-clinically depressed adults. An important detail specific to the exercise-depression relationship is the fact that some studies have concluded that moderate exercise proves more effective than strenuous exercise programs when trying to decrease depression (Moses, Steptoe, & Matthews, 1989). Others have suggested that any type of exercise and any level of intensity can produce beneficial effects with depression. In a meta-analysis of 80 studies, it was concluded that “. . . results provided positive support for a relationship between physical exercise and depression (Scully, Kremer, Meade, Graham, & Dudgeon, 1998, p. 112). A review of the research suggests that regular, moderate, non-competitive, rhythmic exercise, lasting for at least 20–30 min. done in a calm way has the greatest effect of all on mood (Berger & Motl, 2000). This finding might suggest that regular exercise such as walking, Tai chi, swimming, or hatha yoga may be specifically beneficial as a part of the TTB. In a comparison study with medication, Blumenthal and his colleagues (2000) studied 156 older people who were diagnosed with major depression. They were randomly assigned to three groups: one group engaged in exercise alone, one group took sertraline (Zoloft® ), and the third did both. Exercise consisted of a supervised program, for 3 days a week over a period of 16 weeks. All 156 people showed fewer symptoms of depression, regardless of the group they were in. Of those who simply exercised, 60% felt better—about the same percentage as people on medication alone. The researchers were surprised to find that the group who both took sertraline and exercised did not benefit significantly more than either of the other groups alone. Upon evaluation at 6-month follow-up, those who continued their active lifestyle were much less likely to relapse than those on medication. In discussing the benefits of regular, moderate exercise with your patient, you can use the preceding information to show that exercise has a positive effect on mood and results in reduced muscle tension, improved sleep, and reduced levels of the stress hormone cortisol. Exercise, when combined with the other aspects of the TTB, can be expected to result in an overall improvement in energy levels as well as fewer symptoms of sadness,

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anxiety, irritability, stress, fatigue, anger, self-doubt, and hopelessness. For people who take an active part in their own treatment and recovery, they have the added benefit of experiencing a sense of mastery and control over what they are feeling and doing. This provides yet another opportunity for the patient to gain self-confidence, as well as a sense of accomplishment. Be sure to recommend that the patient talk to her primary care physician before starting any exercise program. It is also important for the patient to set reasonable goals even if it means only walking to the mailbox and back at first. Encourage her to choose something she will be willing to continue and possibly will enjoy. Remind her that getting started each day may be the hardest part and at first she might have to “just do it” regardless of what she is feeling. Once she begins to develop a positive mind-set about exercise, it becomes more likely that she will continue with it.

Psychoactive Substances and Mood Alcohol There are several psychoactive substances that may be related to mood problems, alcohol being one of the most common. Be direct with the patient that alcohol is a depressant. Many people use alcohol as a “temporary” means to “numb” out the pain of symptoms. This actually backfires, since they are adding more depressant “medication” to an already depressed system. Alcohol acts on the gamma-aminobutyric acid (GABA) receptor in the brain as discussed earlier in the section on neurotransmitters. Chronic use of alcohol results in down-regulation of the GABA receptor functioning and up-regulation of the glutamate receptor functioning. The long-term result of this process is that the brain adapts to chronic alcohol consumption with a decrease in GABA receptors and an overabundance of glutamate receptors. The individual’s “tolerance” to alcohol increases, requiring larger amounts of alcohol to achieve the same effect, and if alcohol is removed, physiologic withdrawal ensues. Due to the up-regulated glutamate receptors, individuals will most likely experience irritability, depression, disturbed sleep patterns, and anxiety. They will often respond by increasing intake of alcohol to “treat” these symptoms. In addition, they may complain about the symptoms

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to their primary care practitioner or other health care provider. Often they are misdiagnosed with depression and/or anxiety and are treated accordingly. Those who drink excess alcohol are especially prone to folic acid and other nutritional deficiencies which could also contribute to depressive symptoms. If your patient is using alcohol regularly in equivalent amount of two ounces per day or three or four times a week, this needs to be a focus of therapy and the need for medical detoxification should be considered under the supervision of a physician. She can be re-evaluated for mood disorders after she has successfully withdrawn from alcohol. You may decide to continue to provide psychotherapy during the intervening period but a primary focus of treatment needs to be substance use and abuse. Sometimes the mood disorder is no longer present 1 year post-detoxification from alcohol.

Caffeine

If the patient is also using caffeine in amounts more than one or two cups of coffee, or one or two sodas or energy drinks a day, she has developed a tolerance to stimulants which complicate matters in depression. She may be using caffeine to self-medicate some of her symptoms of depression. She will likely feel more depressed as the stimulants effects wane and may feel lethargic, irritable, and experience disrupted sleep patterns. If she stops suddenly she will likely experience a headache as well. The best plan for this patient is to slowly decrease caffeine intake in order to avoid withdrawal headaches. If the patient is using stimulant drugs regularly, regardless of whether or not they are prescribed, withdrawal needs to be supervised by a health care practitioner trained in this specialty.

Medical Conditions and Depression The Medical/Physical Information Sheet (see Chapter 2 on assessment) can also be useful in your assessment to understand the patient’s possible physical manifestations of depression, identify possible medical

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conditions that could be contributing to her depression, determine the need for a referral for medical evaluation, and identify specific physiological, genetic, or physical vulnerabilities. You can give it to your patient in a pre-evaluation packet of materials, or at the first visit as a homework assignment (a copy is provided in the appendix, as well as in the patient workbook). It may be more detailed and comprehensive than might be needed in all cases. If so, use it as a guide to help you with questions to ask your patient. Such inquiry does not substitute for a medical evaluation and this must be explained to the patient. If the patient has not seen her physician within the last 6 months prior to therapy and is reporting fairly severe vegetative signs of depression, a medical evaluation with full blood work is essential. If not, and the patient reports no physical signs or symptoms suggesting the need, usually an annual medical evaluation is sufficient. If she reports recent or current physical symptoms, she should be referred for a medical evaluation of them, regardless of the date of her last medical evaluation, for physical conditions that can mimic depression. If disease or other physical malady is ruled out, you may then proceed with the treatment methods in the TTB. You should not assume that your patient’s aches and pains are simply depressive equivalents. Many treatable medical conditions masquerade as depression, including hypothyroidism, anemia, congestive heart failure, sleep cycle or sleep apnea, nutritional deficiency, chronic viral pneumonias, transient ischemic attacks (TIAs) or cerebrovascular accidents (CVAs) in the elderly, parathyroid disorders, early dementia, pancreatic or GI cancer, chronic infections, and Parkinson’s disease. Physical problems involving pain (head, abdomen, stomach, and joints), muscle tension (frequent muscle strain, cramping, and so forth), and other vague physical discomfort also should be medically evaluated. In specific cases, it may be important to request information from the patient’s health care provider to shed light on medical, physiological, organic, or medication-related problems. For example, when you determine the need, or when someone is referred for psychotherapy by her health care practitioner who is treating her for medical conditions, it would be helpful to have an ongoing open line of communication. This, of course, would require the appropriate Release of Information forms to be completed by the patient.

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Depressive disorders with specifically strong biological components include post-myocardial infarction depression, as well as medical conditions specific to women such as postpartum depression, menopausal onset depression, and premenstrual dysphoric disorder. Some necessary medical treatments also have serious depressive side effects. Patients suffering from cancer, cardiovascular disease, dementia, diabetes, conditions involving chronic pain, Parkinson’s disease, and stroke often exhibit depressive symptoms associated with their illness. These patients may also develop somatic complaints that are typically associated with depression, such as pain, low energy, and sexual dysfunction and physical symptoms such as fatigue, weight loss, and lack of interest in sex. Serious medical conditions commonly associated with depression and medical treatment pose specific challenges in effectively using the TTB. Nevertheless, the patient can be assisted in developing additional coping strategies and encouraged to find meaning in effectively coping with the realities involved in her life, some of which she cannot control.

Post-Myocardial Infarction Depression Major depressive disorder occurs in 15–30% of individuals who have had a myocardial infarction (MI) or heart attack, but it has not been understood whether the resultant depression is due to fear associated with a potentially life-threatening event, changes in self-image, energy, physiological changes, or a combination of all of the factors. Researchers have now discovered that there may be neurobiological mechanisms involving the limbic system, and cytokines related to depressive episodes after acute myocardial infarction (Wann, Bah, Boucher, & Courtemanch, 2007). This is very interesting and hopefully useful information in that someday it may lead to interventions that can either reverse or repair this process. The usual symptoms of depression are evident in addition to the physical effects of fatigue, low energy, anxiety regarding the possibility of future MIs, and the specific automatic thoughts and underlying maladaptive beliefs related to forced changes of role and identity, losses associated with physical restrictions and disabilities, and dealing with fears and worries about the future. TTB can be effective and should be tailored to assist the patient dealing with these specific issues.

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Specific Depressive Conditions in Women The following types of depression have significant biological components that affect women and may require special considerations, both from a medical and interpersonal perspective. For example, a woman with one of these conditions may feel more comfortable working with or may be particularly receptive to a female clinician whom she believes can be more understanding and empathic of her condition and situation. Medical evaluation and continued follow-up will be important.

Postpartum Depression

Postpartum depression is an extremely serious condition that affects between 8 % and 20% of women after pregnancy, especially during the first 4 weeks. It is necessary to seek medical attention to treat postpartum depression. There are multiple factors involved, many physiological. During pregnancy, the levels of estrogen and progesterone increase tremendously. Following the birth of the infant these levels drop. Unfortunately, thyroid hormones also decrease. During the birth process there is often blood loss and the mother usually gets little sleep. Lastly, she is experiencing tremendous stress: loss of prior identity, uncertainty in her new role, and a multitude of other stressors (Ross, Murray, & Steiner, 2005). Most of the symptoms are the same as in major depression with the addition of extreme ambivalence or negative feelings toward the baby just when the mother believes she should only have loving feelings. Once a woman experiences an episode of postpartum depression, her risk is increased for subsequent episodes of depression, both in the postpartum period and at other times. There are special considerations in the treatment of a woman with postpartum depression. She may need more active support from family members and significant others in the everyday management of her responsibilities such as child care. Collateral contacts and/or family therapy may be useful. She may have decided not to take antidepressants during her pregnancy but wants to consider doing so after the birth of her infant. She will likely need focus on automatic thoughts and maladaptive beliefs specific to her role and responsibilities as a woman

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and new mother. The relapse prevention plan should include specific plans to protect against the vulnerability for future episodes. It is wise for a woman who has experienced postpartum depression to thoughtfully plan for future pregnancies and to seek psychotherapy during subsequent pregnancies.

Menopausal Onset Depression

Menopause is an increased risk factor for depression (Cohen, Soares, Vitonis, Otto, & Harlow, 2006). In a study it was found that premenopausal women who entered perimenopause with no lifetime history of major depression were twice as likely to develop significant depressive symptoms as women who remained premenopausal (Cohen et al., 2006). Hormonal changes as well as midlife developmental and psychological issues arise and require special attention. It may be particularly difficult for a woman who has enjoyed a sense of mastery in her life and competence in her role to begin to question herself. Physical symptoms associated with menopause such as hot flashes, fatigue, appetite, and sleep disturbance can be troublesome as well as the usual symptoms associated with depression. Memory disturbance and insomnia can be particularly demoralizing and affect work functioning. A woman seeking psychotherapy during this period can benefit from the TTB program, specifically the cognitive module relating to the specific thoughts and underlying beliefs associated with developmental challenges and role changes (The T of the BEAST). She may need to be referred for a medical evaluation to evaluate medical options, including an array of natural remedies.

Premenstrual Dysphoric Disorder

A form of depression exclusive to women, premenstrual dysphoric disorder (PMDD) is a syndrome of depressive symptoms brought about by monthly hormonal fluctuation. Researchers estimate that PMDD affects between 3% and 8% of women in their reproductive years.

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Symptoms typically occur during the last week of most menstrual cycles and usually improve within a few days after menstruation starts. Symptoms of PMDD are similar to those of premenstrual syndrome (PMS) but are generally more severe and debilitating. In addition to the usual symptoms of depression, PMDD may include panic attacks, mood swings, greater irritability or anger, and physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain. In applying the methods and interventions of the TTB, it may be necessary to focus on the affective regulation, overall health habits, and specific thoughts and underlying beliefs associated with the cyclic nature of the disorder. It is always recommended to avoid caffeine and alcohol for any depressive disorder, especially PMDD. A woman’s health care practitioner can discuss with her the specific treatment options for these conditions. Some women obtain benefits from nutritional supplements in moderation such as vitamin B6, calcium, and magnesium. Pain relievers such as aspirin or ibuprofen may help for headache, backache, menstrual cramping, and breast tenderness. Diuretics may be useful for women who have significant weight gain due to fluid retention. Over-the-counter preparations for PMS that include herbal supplements containing chamomile have been useful as well. Whatever supplements the woman is taking should be discussed with her prescriber in order to avoid drug-drug interactions or potential psychiatric complications from herbal preparations.

Medication Related to Depression Many necessary medications for serious medical conditions have side effects of depression. In addition to these, some of the patient’s depressive symptoms are related to the effects of the illness itself, as well as the psychological reactions associated with having a serious illness. All of these can be addressed with the TTB specifically tailored to the symptoms and underlying emotions, automatic thoughts and underlying maladaptive beliefs, as well as enhancing the patient’s coping and adaptive abilities. Although therapeutic goals may need to be carefully determined in relation to realistic limits, the patient can be assisted in developing additional coping strategies.

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Combination treatment of Hepatitis C viral with interferon (IFN)alpha plus ribavirin is extremely effective. However, one of the most common side effects is depression. Some individuals with Hepatitis C develop thyroid disorders and anemia (as well as other medical conditions) that may account for some incidences of depression in these individuals but the majority is still attributed to the IFN (Asnis & De La, 2006). The science has not developed definitive answers as to the best preventive medical treatment options for depression as opposed to restorative treatment. Chemotherapeutic regimens for cancer pose side effects of depressive symptoms including insomnia, irritability, agitation, extreme fatigue, and memory and concentration disturbance. Other side effects of these medications, such as extreme muscle pain and weakness, peripheral neuropathy, balance problems, and enduring low energy and fatigue, pose additional psychological challenges in coping over time. Long-term aromatase inhibitor treatment following chemotherapy for breast cancer, and hormone treatment following treatment for prostate cancer, can pose troublesome emotional as well as physical effects. Patients facing serious, life-threatening illness may require a more supportive approach or opportunity to discuss deeper, existential questions related to living and dying. Many patients report that through the process of dealing with the life shock of being diagnosed with a serious illness and contemplating the eventuality of their own death allowed them to learn to appreciate and find meaning in life and experience it more fully than they had previously. Prednisone and related drugs such as corticosteroids including ACTH may activate a manic episode in almost any person with a potential for bipolar disorder and anxiety reaction in most anxious or depressed individuals. Many people experience agitation, racing thoughts, restlessness, and insomnia. Prednisone is prescribed for a variety of conditions such as asthma and severe allergies and is included in chemotherapy regimens and following organ transplants to reduce physiological responses and rejection. When discontinuing prednisone, dosage must be gradually tapered in order to prevent a serious physiological withdrawal syndrome, sometimes of life-threatening proportion. Patients must be monitored for suicidal ideation if prescribed this medication.

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Other medications used for sleep and pain management that have depressogenic qualities are sedative/hypnotics and include barbiturates, benzodiazepines, chloral hydrate, and opiates. These are highly addictive and pose great potential for abuse.

Biological Treatment of Depression As evident throughout this book, depression is not explained by a simple cause-and-effect relationship between biology and mood. Since the development of SSRI’s, there has been a resurgence of interest and promulgation of biological psychiatry, especially in the treatment of depression. Medication may be extremely helpful for many people in the treatment of their depression, although it is not always necessary.

In 1987, the U S. Food and Drug Administration approved the sale of fluoxetine hydrochloride (Prozac® ) for the treatment of depression. In 1988, it became commercially available. This action revolutionized the psychotropic treatment of depression and began a cultural revolution as well. Prozac was considered by some to be the cure for depression and in the book Listening to Prozac (Kramer, 1993) it was even marketed as a personality enhancement. It entered the culture by being featured on magazine covers, as the subject of novels and movies, and topics of cocktail parties in the 1990s. had it not been for the NIMH Treatment of Depression Collaborative Research Project and other research showing the efficacy of CBT, psychotherapy in general might have fallen completely out of favor.

The enormous 7-year STAR-D (2006) study conducted by the NIIMH investigated medication treatment of depression and results immediately influenced psychiatric practice with respect to dosage and sequencing. The use of drugs for their augmenting effects had become a common practice in medical management of major depression but the results of the study did raise some questions regarding this practice. The use of symptom checklists, rating scales and side effect measures in monitoring ongoing response was suggested (Rush, 2007). Research does provide support for medical treatment in combination with psychotherapy, most specifically CBT (Wright, 1987; Miller,

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Norman & Keitner, 1999; Keller, McCullough, Klein et al., 2000). Other research indicates that cognitive therapy can be as effective as medications for the initial treatment of moderate to severe major depression, but this degree of effectiveness may depend on a high level of therapist experience or expertise (DeRubeis et al., 2005). A growing body of research suggests that changing the way people think about things is as effective as changing their body chemistry through drugs. Specifically, the value of CBT as compared to treatment with medication has been shown in several important studies. In one such study, Segal, Williams, and Teasdale (2002) focused on relapse. They compared those who had recovered from depression with antidepressants to those who had recovered with CBT. All were evaluated regarding their dysfunctional attitudes and “risky thought patterns,” then in the experimental situation they listened to sad music at half speed, while at the same time being asked to remember a time in their lives when they felt sad. For those who were treated with medication only, even mild sadness was more likely to trigger dysfunctional thinking than for those who were treated with CBT (Segal, 2006). Results also indicated that those whose thinking became most dysfunctional during this exercise were most likely to relapse over the next 18 months. Another study tracked severely depressed patients over 16 months. Subjects received 4 months of treatment; either medication or cognitive therapy sessions, followed by an additional year of follow-up treatment for those whose condition improved. Results were that 75% of the patients receiving cognitive therapy avoided a relapse into depression as opposed to 60% of those on medication and 19% of those who received a placebo. The study showed that even with more serious cases of depression, cognitive therapy was as effective as medication in the short term and provided a superior benefit over that of medication after one year’s time (Hollan et al., 2005). Further research is needed in order to determine whether this effect hold over a longer term. It is important for you to have a good working relationship with a prescribing psychiatric specialist or in special cases, other health care professionals who are knowledgeable, thoughtful, and competent in prescribing psychotropic medication at the appropriate dosage. With an ongoing professional relationship already established, it is easier for you

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to facilitate referrals in those instances when they are necessary. Whether to use medication should be an informed decision that involves careful discussion between the patient and her health care practitioner. This decision may include special attention to such factors as severity of symptoms, pregnancy, potential side effects, history of side effects in prior treatments, and medical and health-related conditions.

Deciding About Medication If the patient is considering whether to take antidepressants, she should discuss her options with her primary care practitioner and/or prescribing psychiatric specialist. Patients currently taking antidepressants should regularly review their medication with their doctor. In some cases, it may be appropriate to give the TTB program a chance to work prior to deciding to take an antidepressant. Of course in other situations you will need to refer the patient for psychiatric evaluation for medication immediately. Such situations may include when the patient has firmly decided she wants to take an antidepressant, if she has had a positive response to medication in the past, if she is becoming severely sleep deprived, if she is so severely depressed that you are unable to engage her in treatment, or is accurately diagnosed with bipolar disorder. Many patients decide that they are unwilling to take antidepressant medication due to these side effects or for other reasons and opt for cognitive-behavioral therapy instead. In these instances, the TTB program may be especially useful. However, in some of these cases you may need to proceed with caution, work more intensively, schedule sessions more frequently, and monitor your patient’s progress more carefully. There is a chart of antidepressant medication at the end of the book for your reference. It is provided as an outline and not intended to be a comprehensive discussion. Even though you may not be a physician or licensed to prescribe medication, it is important to be aware of the main effects and side (secondary) effects. Occasionally medications are prescribed for their “side effects” rather than their main effects, such as in the case of augmenting medication for sleep or appetite disturbance and agitation or anxiety.

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You are in an ideal position to discuss medication with the patient but she should always be referred to her primary care practitioner or prescribing psychiatric specialist to discuss the options and make the decision. Since you see the patient regularly, you are also in a position to assist her in being observant to her responses and reactions to the medication. The Medications Log is an important tool in doing this. The patient can use it as she tracks medication effects and secondary effects and you can use it in her chart in order to do the same.

Side Effects of Antidepressants All medications have side effects. Some side effects are so adverse that the specific medication is contraindicated for that patient. Some side effects may mean that either the medication is being taken in doses larger than necessary, or the medication is not indicated for the type of receptor deficiency that the individual is experiencing. Prescribers may use a trial-and-error method to a certain extent in determining the most appropriate medication and dosage. The individual should be referred back to her prescriber for re-evaluation of medication management.

Other Biological Treatments for Depression Vagal nerve stimulation involves the surgical implantation of a small generator that stimulates the vagus nerve. It is a technique that has been used in the treatment of patients who suffer from complex partial seizures or generalized seizures in which consciousness is lost, and who do not respond to anticonvulsant medication, and patients. It is being investigated for use with patients who are depressed. Deep brain stimulation (DBS) involves surgically implanting electrodes in a specific, targeted area of the brain that are used to deliver electrical charges, developed by Mayberg and her associates. (Mayberg et al., 2005) New research using neuroimiging have provided understanding of the physiological brain changes and specific structures associated with depression that led to its development.DBS has been used with a small number of patients (6) whose depression were unresponsive to conventional forms of therapy. In four out of six patients they found, 68

“striking and sustained” clinical improvement. Mayberg calls the electrodes a pacemaker for the brain and suggests that it “rewires” parts of the brain’s circuitry. Electroconvulsive therapy (ECT) is still sometimes used in cases of severe, intractable depression. It is considered a much safer procedure than might have been the case in the 1950s when it was used extensively. Memory disturbance, confusion and emotional blunting are side effects although reported to be much less so due to the use of weaker levels of electrical current and unilateral, rather than bilateral methods. Transcranial magnetic stimulation (TMS) is a non-invasive technique that uses a powerful electromagnet placed on the scalp of a person to alter brain activity. Originally developed as a diagnostic tool for mapping brain function, TMS induces an electromagnetic current in the underlying cortical neurons and possibly subcortical structures as well. Repetitive TMS (rTMS), using varying frequencies and intensities, can increase or decrease excitability in the cortical area directly targeted by the stimulation. Based on pilot studies and a few early clinical studies TMS was reported to be a promising as a treatment for patients with major depression who had failed to improve with traditional medical treatments. Results of 16 trials were reviewed and most comparisons did not show differences between rTMS and sham TMS and other interventions. The studies also showed ECT was more effective than rTMS. The review suggests that there is no strong evidence for benefit from using TMS to treat depression, although due to the small sample sizes the possibility of benefit is not excluded. Acupuncture has received much popular attention as a treatment for a variety of conditions including depression. Despite much anecdotal evidence suggesting its effectiveness a study comparing effects of specifically tailored acupuncture and non-specific acupuncture were associated with some improvement, indicating a placebo effect (Allen et al., 2006).

Summary and Interventions The Tracking of Mood (TOM) Form is an important tool for the patient to use as she progresses through the TTB program and incorporates information regarding specific vulnerabilities. It can be used as 69

an objective (scores and ratings) reflection of the patient’s incremental improvement. Introduce it to the patient in the assessment phase (see Chapter 2) and explain it further in the socialization phase (see Chapter 3). Explain that it can serve as a valuable tool not only to track progress, but to assess what techniques are most useful and reevaluate the treatment plan during the course of treatment. Instruct the patient to enter BDI scores, ratings of the individual factors, and an overall rating of satisfaction with progress. The form can be used on a daily or weekly basis. It is appropriate to use on a daily basis along with the Activity Schedule to help the patient recognize the temporary nature of intense feelings, variances in mood, and to show the relationship of mood to factors over which she can assert some control, such as activity, exercise, sleep, situational factors, and alcohol and drug use. Once the relationship of these factors is well-recognized, the patient has put into effect behavioral changes and her depression has begun to lift, it is more appropriate to use it on a weekly basis. It also can be used to determine when ending therapy is appropriate, and when therapy is completed, as a part of an ongoing relapse prevention plan.

Homework

✎ ✎ ✎ ✎ ✎

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Have patient review Chapter 4 of the workbook and complete the exercises. Have the patient complete the Physical/Medical Information Sheet, if not already done during the assessment phase. Have the patient complete the Potential Vulnerabilities for Depression Sheet, if not already done during the assessment phase. Have the patient complete the Tracking of Mood (TOM) Form, if not already done during the assessment phase. When indicated, recommend that the patient be evaluated by a primary care practitioner or prescribing psychiatric specialist.

Chapter 5

Emotions

(Corresponds to chapter 5 of the workbook)

Therapist Note

The number of sessions required to complete this module is determined by the therapist according to the specific needs of the individual patient. ■ ■

Materials Needed ■

Feelings Examples Worksheet

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Feelings Log

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I am Aware Exercise worksheet

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Interpretations, Feelings, and Actions Worksheet

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Decision Making Worksheet

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Thoughts and Feelings Worksheet

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Activity Schedule (optional)

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Automatic Thought Record (optional)

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Provide introduction to mood, emotions, and feelings

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Introduce the ABC model of emotion

Outline

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■

Discuss the importance and nature of emotions

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Define the differences between thoughts and feelings

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Introduce interventions focusing on emotion and feelings

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Assign homework

Introduction to Mood, Emotions, and Feelings Depressed mood (dysphoria) and its related reflection in constricted affect is the most prominent symptom of depression. For many, feeling down, low, blue, or sad for even a short time is synonymous with the term depression. So the word depressed is often used when people mean sad and vice versa. In fact, the two necessary criteria for the diagnosis of depression are within the emotional dimension of depression: (1) depressed mood most of the day, nearly every day and (2) markedly diminished interest or pleasure in all, or almost all, activities. We use the term melancholia to describe an almost complete absence, rather than merely diminished capacity for pleasure. When a person is depressed, it is understandable that it would be difficult for him to ignore how bad he feels and be overwhelmed as a result of his negative emotional state. Emotion, mood, feelings, and affect are often used interchangeably. For our purposes, the following distinctions are used. Emotion is an all-inclusive concept involving measurable, complex, psychophysical processes that arise spontaneously, rather than by conscious effort. They may arise in response to internal or external stimuli (“triggers”) and may be described by the patient as a sinking feeling, a visceral sensation of sadness, the increased heartbeat and perspiration that accompany fear, or muscle tension that accompanies anger. In its broadest sense, the concept not only includes physiological arousal, but subjective feelings, cognitive processes, and behavioral reactions. TTB uses the well-accepted, basic categories of emotional states of happiness, sadness, fear, disgust, and anger identified by Eckman and his colleagues (Ekman, 1982; Ekman & Davidson, 1995; Ekman & Freisen, 1984; Ekman, Levenson, & Freisen, 1983).

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Feelings are commonly accepted as being the conscious, subjective experience of emotion. Mood refers to a person’s pervasive and sustained emotional state. In addition to dysphoria, the depressed person’s mood often also includes irritability and anger. Affect refers to the outward (usually facial) manifestation of a person’s feelings, tone, or mood. In depression, one’s range of affect is usually restricted, constricted, or blunted. Various emotions and feelings may be experienced at the same time. When “mixed feelings,” or even contradictory emotions are present, the patient may experience a conflict between positive and negative emotions or feelings. It may be helpful to assist the patient in realizing that he may have mixed or ambivalent feelings. If a person experiences negative or painful emotions, it is likely he will try to avoid them. This is only natural. This avoidance may be adaptive in some ways, but also leads to the lack of ability to use emotional experience as information in communicating effectively with others, in problem-solving, and in decision-making. Further, over time it limits curiosity, creativity, behavior, new learning, and satisfying relationships. This avoidance can become a fixed pattern and part of the downward spiral of depression.

The ABC’s of Emotion Albert Ellis, one of the pioneers of cognitive therapy, developed Rational emotive therapy (RET) in 1955 and used a simple model to explain how feelings are connected to other factors in one’s life. This model is commonly known as the ABC model (Ellis, 1955, 1961, 1977). This model is still viable today and is shown in Figure 5.1. Activating Event

A

Belief

>

B

Consequences

>

C

Figure 5.1

ABC Model

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Between the circumstances that lead to a change in mood (A, activating event) and the emotional results (C, consequences), an interpretation is made based on underlying beliefs (B). By becoming aware of his biased, irrational beliefs and the distressing emotional fallout that is the consequence of those beliefs, the patient can begin to understand them and then change. Use the following case example to show him how the ABC model is applied. Have him follow along using the same example in the workbook.

Case Example Lisa had been sad for days because she thought she failed a test in school. She had a very high grade point average and had seldom performed poorly on tests. However, Lisa continued to worry and even imagined herself failing the course and eventually having to quit school because of her poor grades. Unfortunately, after almost every exam she took, Lisa experienced this period of sadness and had similar worrisome thoughts about her future. In Lisa’s case, the activating event (A) is waiting for the results of the exam she completed. Her belief (B) is that she is not smart enough to pass the course and that she will eventually have to quit school because of poor grades. The consequences (C) of this belief are feelings of sadness and worry. Despite evidence to the contrary, Lisa maintains a belief about herself that makes it hard for her to feel confident about her efforts. She has so much self-doubt that it seems to override her perspective on overall performance, past efforts, and positive sense of the future. Instead, she feels sad and worried, in large part because of an unfounded, unreasonable belief (B). Many people get stuck (habituated) in their dysfunctional thinking patterns by attributing the basis of their problems to just one single global factor, rather than multiple factors. There are both external and internal factors that affect mood, and in this program the patient will consider how he and the situation interact. People who are feeling depressed may try to find the “core” reason or single cause for their emotional pain.

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Most of the time, they end up frustrated by their search and feel worse. As a result, many come to the misguided conclusion (core belief ) that they are somehow defective or worthless as a person. It is much more productive to search for and change several different factors to improve mood, rather than to seek the elusive key or “root cause” of all their problems. The basis of the clinical practice of CBT and this particular program is teaching the patient that depression is a function of multiple factors: biochemistry (biology), feelings (emotions), behavioral level (activity), the world around him (situation), and his thinking patterns (thoughts). The patient himself is in the position to learn how these factors interact and gain greater control over his depression, thereby taming the depression “BEAST.” Typically, the CBT therapist’s first level of intervention into this complex system is in automatic thoughts, underlying thinking patterns, and related core beliefs. Specific therapeutic focus on emotions themselves is sometimes important as well. An overall goal of the TTB program is to help the patient achieve a balance in thinking and feeling, rather than promoting thinking to the exclusion of feeling.

The Importance of Emotion Basic emotions are important to human existence. They serve as signals to take action or to accommodate in ways that are necessary for survival. When they are interpreted correctly the appropriate action can be taken. In this way, by their nature emotions are temporary. Such is not the case in depression. In depression, feelings are misinterpreted and often it is one’s reaction to the sadness that maintains it. What could otherwise be a natural, temporary period of sadness becomes a sustained low mood when a person negatively reacts to the emotion itself and sets in motion the downward spiral of depression. Emotional experience is crucial to pleasure, satisfaction in relationships, and an overall sense of well-being. In contrast, emotional reasoning is a dysfunctional thought pattern that leads to maladaptive decisions and behaviors and is a prominent part of depression. It may reflect the belief that if you feel something, it must be true and therefore it

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should be acted upon. When someone thinks his negative thoughts are true because he “feels” them so strongly, he may eventually find himself “feeling” so badly that he begins limiting his activities, avoiding others, eating poorly, despising himself, and spiraling further into the depths of depression. This tendency can be illustrated to the patient by directing him to the exercise in Chapter 5 of the workbook regarding thoughts, interpretations, feelings, and actions (see later section on interventions for focusing on emotion and feelings). In general, when a person is depressed, it is not usually a good idea for him to rely on his feelings as the sole basis for making decisions.

Gender Stereotypes Gender stereotypes, though more subtle than previously recognized, still may be apparent in our culture with respect to emotional expression. Be sure to take this into account when working with the patient. Even though women are often permitted greater emotional expression than men, at other times they are criticized for being too emotional. Conversely, men are not permitted the freedom of emotional expression, while at the same time are often criticized for lacking in emotional expression. Boys and men in our society often have been taught that expression of feelings such as fear or sadness is not masculine. They may experience shame when they do express these feelings and often refer to the experience as “breaking down.” Girls and women were previously taught that assertiveness and expressions of anger are not acceptable and sadness and fear are feminine. Sometimes when they do assert themselves or express anger they are criticized and accused of trying to be like a man.

Variations Among Individuals Valuing of emotional experience and expressiveness varies among individuals due to a variety of factors, including temperament, developmental experiences, personality features, and cultural attitudes. These differences become important in understanding depression when there is imbalance or if attitudes toward feelings are on the extreme end of the

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continuum. Examples of these extremes are reflected in the following underlying beliefs that may be evident in how people make important life decisions, solve problems, and relate to others: ■

Feelings are the MOST important consideration in human relating.

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Feelings MUST be expressed or discharged in order to be honest.

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Feelings are NOT important, only sentimental or sappy.

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Feelings MUST NOT be expressed, doing so would be overwhelming or dangerous.

The Nature of Emotions or Feelings Differences in the range of feeling and emotion are, in part, related to individual differences in physiological factors and temperament. If you are working with someone for whom low mood is a specific vulnerability this is an important aspect to teach. During the course of psychotherapy, the patient can come to accept this vulnerability as a reality much the same as a person who, because of his unique physiological characteristics, might gain weight more quickly. As he learns a set of skills with which to manage his depression, more acceptance and self-compassion can develop. Another important feature of feelings that is often ignored by depressed people is their temporal nature and the fact that emotions may ebb and flow. Most depressed people believe that their feelings are permanent and depression is enduring. Many patients are actually surprised to discover, by use of the Activity Schedule, Automatic Thought Record (ATR), or Feelings Log, that their feelings in fact do vary in intensity over time, even when their mood is depressed. Even minimal variances can be used as evidence to demonstrate to the patient the transient nature of his feelings. As the therapist, you can model this appreciation in the language you use. Rather than saying things like, “You seem to be feeling much better now” or “You don’t seem to be depressed anymore” it is preferable to invite your patient to be aware of slight variances by saying statements like, “From what I observe right now,

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it seems that you are feeling not quite as low as you were when we first came in” or “Did you notice on Thursday, that when you got up and got dressed you felt a little better?” Those who are depressed are global in their view of their depression and anticipate future negative experience, but not their brighter periods. They are reluctant to accept global statements and will actively resist them with comments like, “Well I still feel depressed” or “I know when I leave here I will feel bad again.” The meanings of feeling states are specific to individuals and may be created, attached, and believed in varying degrees, depending on their maladaptive thinking patterns, developmental experiences, a result of teaching, and other culturally shared values. These meanings need to be explored. The Socratic method of inquiry is especially important as you talk with your patient. You may begin this inquiry with the following sample dialogue: You say you are depressed yet as I hear you describe your experience it sounds like you are also really critical of yourself. What are some things you tell yourself about your own depression?

The Difference between Thoughts and Feelings We commonly hear people interchange thoughts for feelings and vice versa. In response to an inquiry of how a person is feeling, he might respond, “I feel like my life has been a failure.” Sometimes when advice is requested or given, a person might say, “What do you feel I should do?” or “I feel like you should tell your mother to leave you alone” or “I feel like people should be more fair” or “I feel like it was just horrible what John did to me.” It is important to recognize that by interchanging thoughts and feelings and vice versa, each is obscured. When you hear such statements you are alerted to the need for education about the differences between thoughts and feelings. It may, in fact be one of the first avenues of intervention in dealing with emotions in psychotherapy. By understanding these differences, the patient can become more aware of how his thoughts and feelings are distinct yet related.

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Interventions Focusing on Emotion and Feelings Once a feeling is generated and not understood, it can take on a life of its own, become exaggerated, and be repeatedly reactivated. There may be a delayed return to the baseline or set point and contributes to being even more easily reactivated in response to the next stimulus. Such is the case in depression. You can assist the patient in affect regulation by engaging him in specific interventions. Gaining awareness, and acknowledging and understanding the nature of feelings are important elements in the program. We propose that people identify and accept feelings as “what is”—as a natural part of the human experience. When we can acknowledge our feelings, we are in a position to make informed decisions about what to do with them, rather than to feel victimized by them, express them only in the maladaptive, habitual ways that have been learned over the years, or try to obliterate them. You can propose to the patient that he can learn to reduce external or internal stimuli that “triggers,” reactivates, or intensifies emotions and maladaptive responses to them. At many points along the process, the patient can learn to intervene by sometimes changing his situation, modulating his physiological activation, and restructuring associated appraisals, thoughts, and expectations. In decision-making and in problem-solving, he can learn to acknowledge his emotion as another aspect of experience (evidence) to be evaluated and considered as opposed to being his sole basis of decision-making. The patient can choose how he acts on his feelings in accordance with his own personal ethics, values, and goals, and by using this process can actually begin to appreciate them as a valuable part of his overall life experience. Just as it may be maladaptive for the patient to be unaware of his feelings, it is more typically the case that when he is depressed, he is too acutely aware of his painful feelings. Often the first therapeutic endeavors are to help the patient gain emotional distance from his intense, overwhelming feelings. The Activity Schedule is usually used first to facilitate this. When overwhelming dysphoria is present, it is important to discuss with the patient the nature of emotion, and its relationship with activity and thinking. The Activity Schedule is discussed in

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more detail in the following chapter on activity. You may judge that the patient needs assistance in identifying and naming his own feelings prior to the introduction of the Activity Schedule.

Self-Compassion and Emotion Depressed individuals often have little self-compassion as reflected in their prominent negative view of self. While self-compassion has only recently been the focus of attention in Western psychology it has been a prominent aspect of one of the world’s oldest traditions of mind training and wisdom; that is Buddhism (Brach, 2003; Coleman, 2003). Self-compassion is an accepting stance toward aspects of oneself has been as a healthy form of self-acceptance (Neff, 2003b). Its three main components are: (1) being kind and understanding; (2) having a sense of shared humanity and recognizing that pain and failure are unavoidable aspects of the human experience; (3) and a willingness or ability to face, rather than avoid painful thoughts and feelings, but without exaggeration, drama, or self-pity. (Neff, 2003b). Neff and her colleagues conducted a study among 177 undergraduates that showed significant positive correlations with self-reported measures of happiness, positive affect, optimism, personal initiative, curiosity, agreeableness and conscientiousness, and significant negative correlations with negative affect and neuroticism. These results were interpreted to show that self-compassion predicted significant variance in positive psychological health beyond that attributed to personality variables (Neff, Rude, & Kirkpatrick, 2007). Another area of preliminary research suggests possible relationships among compassion-meditation, and reductions in inflammatory and behavioral responses to stress linked to major depression and a number of medical illnesses (Raison et al., 2008). Future research will be needed in order to clarify these relationships and provide empirical support of self-compassion and its role in psychological health and well-being. Such research may very well have exciting implications in the treatment of depression. However, at the present time gaining self-compassion is still a valuable therapeutic goal, if only to help the patient relieve himself of the agony of his self-assaults.

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Therapist Note

If you determine that it would be helpful to further assess your patient’s self-compassion, you can download a Self–Compassion Scale at www.selfcompassion.org. ■

■

When you begin to intervene at the level of feelings and deeper emotion with your patient it is important to appreciate the goal of helping him to be patient with himself and gain self-compassion. Without doing this, the patient could become even more self-critical and depressed. He may not understand the distinction between self-compassion and feeling sorry for himself. He may think that acknowledging and accepting his feelings will result in him staying depressed forever. Rather than recognizing acceptance as an important first step in change, he may believe that if he accepts himself as he is, he will lose the motivation to change. The self-compassion exercise in Chapter 5 of the workbook is useful in guiding the patient to understanding how he might have learned to be self-critical, then became dependent on his own self-criticisms as motivation. Your own empathy will be important modeling in helping your patient realize that he can become self-compassionate, at the same time challenging himself to acknowledge and accept his mistakes, and move forward to make constructive changes in his life

Identifying and Naming Feelings A useful way to identify feelings is to ask the patient to name as many feelings as he can during a session, using the Feelings Examples Worksheet in Chapter 5 of the workbook. Keep in mind the basic emotional states of anger, disgust, fear, joy, and sadness (Ekman, 1982; Ekman & Freisen, 1984; Ekman et al., 1983). Some patients may be able to readily recall a broad range of feelings from their own experience and note differences in intensity and valence, making the Feelings Examples Worksheet, Feelings Log, Automatic Thought Record, and Activity Schedule appropriate homework assignments, depending on the patient’s individual needs. If the patient has difficulty generating his own feeling-words due to lack of knowledge about feeling states, emotional naivety, poverty of

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thought, or slowed thinking process; or has difficulty recalling a range of feelings because of negative bias or selective perception, he may benefit from further education and discussion. Use the Feelings Examples Worksheet as a basis to further expand the patient’s awareness of different feelings and his ability to identify them from his own past experience. It is best to first use this as an exercise within the session so you can coach him as he goes through the list and tries to recall examples from his own experience of when he experienced the specific feeling. For example, he might write, “I felt affection for my daughter when I saw her playing and singing to her doll.” Or “I felt compassion when I saw the homeless family waiting in line at the shelter and wanted to help them.” Or “I felt envy when I saw my neighbor drive home in his new car.” When the patient has completed the exercise it can be used for future reference in expanding his repertoire of language to work on future homework assignments and expressing his emotions in his life.

Recognizing Variances in Intensity, Valence, and Duration Both the Feelings Examples Worksheet and the Feelings Log are useful in assisting the patient in being aware of his different feelings and appropriately identifying them. The Feelings Log is also useful as a means of beginning to perceive intensity of feelings on a continuum, rather than in an all-or-nothing way. Both forms can be used as an exercise within the session or as a homework assignment and serve as transition exercises to using the ATR most effectively. They provide important ways for you to assess how attune to his feelings your patient may be and whether more education is needed with respect to emotional states, affect regulation, and expression. They can provide useful information to you and the patient regarding the depth and range of feelings experienced by him prior to his depression, evidence of having come out of depressive episodes in the past, and/or reason for hope for anticipating pleasure in the future as depression lifts. At first, when using the Feelings Log ask the patient to complete only the first three columns. In discussion you may draw his attention to the feelings experienced in the distant past compared to the past week.

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After it is clear that the patient is able to recognize and identify his feelings, he can note variance in intensity, valence (positive or negative), and duration of feelings. For example, if he perceives sadness as weak or unacceptable he can place a minus sign in the corresponding space in column 3. This information may help him understand more of why it is difficult to acknowledge some feelings over others. The Activity Schedule and ATR are also useful in this regard as means of recognizing variance in intensity and duration of intense feelings, but the Feelings Log is appropriate when the therapeutic focus is more specifically on feelings. A copy of the Feelings Log is provided for the patient in Chapter 5 of the workbook.

Awareness Exercises If the patient needs more assistance in identifying his own feeling and emotional states, an awareness exercise may be useful. A word of caution is important at this point. The patient’s avoidance of his feelings can be understood as unrealized (yet learned) coping strategies against imagined dangers. The goal of this exercise is not to encourage abreaction necessarily, rather to help the patient be more aware of physiological responses as signals to feelings and to accept his feelings without judgment. You can use the Socratic method of inquiry to explore what underlying judgments or beliefs about his feelings and expression of them could be present reflected by his entries in column 3 of the Feelings Log. These can be explored and challenged in much the same way as outlined in Chapter 8 on thoughts. By working in this way, over time the patient may naturally allow himself to express his feelings more freely, effectively, and appropriately. The patient may resist acknowledging and experiencing his feelings out of concern that depression will worsen. It is more probable that gaining awareness in this way of specific feelings and related thoughts can break down a global, overwhelming depression into its component parts which are more amenable to intervention. Awareness and relaxation exercises are useful in this regard. Both practices offer ways of assisting patients in becoming aware of internal experiences; physiological and mental, without judgment. Its clinical

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application offers some helpful techniques when it may be important to provide the patient guidance in identifying, differentiating or experiencing feelings more directly. One example of this might be the patient who has unresolved bereavement or losses and together it becomes apparent it would be useful to face those feelings more directly in the process of working through them. Another example might be the patient who seems to have no problem expressing anger yet seems to be out of touch with sadness. If this is the case, it may be important to assist the patient in accepting his feelings as they exist and realizing his responses to his feelings may be part of the problem. For example, he might be frightened that if he accepts his feelings that means he is giving-in to the status quo. He might believe that they will overwhelm him. It may be helpful that emotions are a complex phenomenon that “he” experiences. There is an “I” doing the experiencing, rather than the feelings defining the “I.” This may be the first step to helping the patient gain some acceptance of his feelings and at the same time some useful distance.

Awareness Exercise 1

In session, invite the patient to become aware of his bodily sensations and associated feeling interpretations in a kind of a “body scan of awareness,” specifically suggesting focus on different parts of the body, one by one (Benson, 1984; Benson, H., with Klipper, M. Z., 1975). If he seems distracted by external things you might ask him to close his eyes. As you go, ask the patient to tell you what he notices. This can be a short exercise (2–5 minutes) and is used to help the patient become aware of his feelings in relation to his bodily experience in a non-judgmental way.

Awareness Exercise 2

Similarly, the “I Am Aware” exercise may be useful in helping the patient acknowledge his feelings as well as identify external (or at times, even internal) stimuli that act as signals or “triggers” for activating habituated responses. It involves the patient first reporting to you what he is

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aware of externally, such as the sensation of the air-conditioned cool breeze, the softness of the chair, the sound of the leaf blower outside, or even changes in your facial expression. Then ask the patient to report the bodily sensations, feelings, or thoughts he becomes aware of in response to these specific things he notices, one-by-one. Do this for 2 or 3 minutes. For someone who tends to overreact to bodily sensations and over-interpret them or worry that he has a medical illness, the same exercise can be done with focus guided to internal, rather than external stimuli. Following the exercise ask the patient to describe and rate his responses on the I Am Aware Exercise worksheet in Chapter 5 of the workbook. Should you and your patient consider these exercises useful you can also assign them as written homework, which might prove useful in preparing the patient to use the ATR most effectively.

Techniques for Appreciating Changes in Mood Intensity When a person is severely depressed he typically feels it intensely. Many times a person is not aware of his associated thoughts, behaviors, or situations that accompany fluctuations in mood. Dichotomous perceiving is recognized by its “all-or-nothing” quality evident in the patient’s descriptions of the intensity of his mood states. This aspect of depression is discussed with the patient when he is socialized to the TTB program. It may be evident on the Activity Schedule, in which the patient rates his experience of mastery and pleasure (see Chapter 6). The patient might rate his depression as 10 on a 1–10 scale on the Activity Schedule and report that it has been at the same level of intensity for weeks or months. If this is the case, it may be important to discuss the possibility of perceptual bias and assist the patient in reconsidering ratings in comparison to past experiences or imagined future experiences. The Activity Schedule, Automatic Thought Record, and Feelings Log are all useful in providing evidence from the patient’s own life in re-evaluating his perception of his own emotional experience as well as recognizing that his mood does in fact vary over time and does not remain at the same painful or grinding level of intensity. Such appreciation is important in recognizing incremental changes as the therapeutic work progresses.

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Specifically it can be used to help your patient appreciate that intense feelings are usually time-limited (don’t last forever) and vary in intensity.

Scaling

In addition to the Activity Schedule and ATR, another intervention method of rating the intensity of feelings and demonstrating variances in intensity that may have been previously unrealized is referred to as scaling. As a means of introducing the scaling exercise, first ask the patient to think about his most pleasurable experience in life and rate it. Then ask for his most unpleasant experience and ask him to rate that as well. If the patient has difficulty with the 1–10 point scale, consider using a 1–100 point scale and asking specific questions about common experiences to encourage greater range or variance.

Feelings Log

The Feelings Log is also a useful tool to show variance in intensity of feelings as well as the ebb and flow (duration) of them. Start with the patient’s partially completed Feelings Log (first three columns). In session, begin by asking the patient to rate the feelings he listed as either positive or negative (column 4) and to rate the degree of intensity of each one (column 5). Be aware of subtle difference in intensity and invite the patient to notice them. In those cases in which feelings can be “normalized,” as in the case of loss or disappointment, this is important to emphasize.

The Relationship Between Thoughts and Feelings When people accept their own automatic perceptions as the “truth” of external reality, they need assistance in appreciating that their perceptions and related feelings can be challenged, modified, diluted, or even changed. However, your patient will likely feel discounted or misunderstood if you immediately ask him to question his own perceptions

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or feeling experiences. This is one of the primary reasons the Socratic method is preferred. When the method is first used you begin to ask questions that promote interest and self-curiosity, without judgment. It is better to think of beginning a line of inquiry, rather than simply asking a host of questions. The patient may be able to more readily understand how interpretations may play such a prominent part of his experience by first considering a more emotionally distant example, one from someone else’s experience. From this perspective, the patient may become more accepting of how his own interpretations play a role in sustaining his own depression. Direct the patient to the Interpretations, Feelings, and Actions Worksheet in Chapter 5 of the workbook.

The Automatic Thought Record (ATR) The ATR is the most commonly used tool in conducting CBT and an integral part of the TTB program, whether beginning with thoughts first or feelings. The previously presented worksheets can be useful in assisting your patient in making the most effective use of the ATR in further identifying his feelings, automatic thoughts, and the relationship among thoughts, interpretation of events or situations, and feelings. Through the use of the ATR, it will be possible for you and your patients to also understand their underlying beliefs and schemas. See Chapter 8 on thoughts for more detailed instruction for using the ATR.

Developing Capacity for Pleasure Just as individuals vary in how they experience feelings, they vary in how they experience pleasure and appreciate humor. However, the symptom of anhedonia represents a decline in this capacity. There may be specific impediments in the patient’s present capacity to experience pleasure and humor that can be alleviated. The next chapter on activity (the A of the BEAST) details specific interventions designed to develop increased awareness or capacity for pleasure and regaining an appreciation of humor. With specific respect to developing awareness, a simple, in-the-moment experiment within a session is useful. Ask your patient to look around your office and see if there is anything that stimulates

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even the slightest bit of curiosity, interest, or pleasurable response. If there is any positive response at all it can be acknowledged and used as an example of how his receptivity or capacity for curiosity, interest, or pleasure may be enhanced.

Decision-Making One of the skills a depressed person loses is the ability to make choices and decisions in an effective manner. One of the reasons for this is that despair colors expectations and hopelessness and helplessness ensue, resulting in an emotional bias. Often the view of alternative choices is constricted. Confidence is weakened and optimism regarding the consequences of choices is lost. As was previously stated, it is not usually a good idea to make important decisions when your patient is depressed. The previous interventions related to identifying feelings, recognizing differences between thoughts and feelings, and using the ATR provide a solid basis to guide the patient in using his newly gained understanding, self-awareness, and insight in his decision-making process. As in other skills, it is important to start with easier, less consequential decisions before tackling the life-changing ones, such as “Should I get a divorce?” or “Should I drop out of graduate school?” Traditionally, weighing the advantages (benefits) versus the disadvantages (costs) of different options in decisions has been used in CBT. However, the use of emotions in the decision-making process is not usually systematically considered. We propose that emotions are an important consideration when balanced with thoughtful judgment. This is wisdom. When the patient seems helpless to know what to choose, or stuck regarding a decision to be made, the Decision Making Worksheet may prove useful, whether the decision to be made is simple or has lifechanging consequences. If the decision is immediate, then the outcomes will be evident and can be reviewed in the next session. It is better for the patient to practice and realize some success in using the worksheet first with simple decisions like inviting a friend to dinner, before using it to make life-changing decisions such as asking someone to marry him,

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filing for divorce, or making a mid-career job change. A copy of the worksheet is provided for the patient in Chapter 5 of the workbook. Ask the patient to describe the decision to be made at the top of the form. In the first column, list the various options to consider. Assist the patient in expanding the list of options for consideration by asking for all the possibilities he can think of. Then ask him to narrow down the list to only those he would be willing to consider. Leave enough space between each option to write information in each of the other columns. In serious decisions, the patient could use a separate sheet for each option to allow room for the related issues to be fully explored. Next ask the patient to list every pro and con statement that he can generate. Insert the related feeling(s) option in the Current Feelings column and rate its intensity on a scale of 1–10. Now, direct his attention back to the first line and ask the patient to write a few words about what he has learned about the specific feeling(s). For example, he might state that the feeling is related to a distorted belief or automatic thoughts that do not serve him well. If that is the case, specific negative consequences can be listed. When encouraged to compare the two sets of feelings, the patient may be able to make decisions with more clarity, self-awareness, and in a more reasonable way. In summary, the relationship of thinking and feeling is the basis of the cognitive model of depression and the cognitive-behavioral treatment of depression. The interventions discussed in this chapter can be used with the patient when basic education is needed about emotions, when interventions are needed to manage overwhelming affect, or when the emotion element of the spiral of depression appears to be the most amenable to treatment.

Homework

✎ ✎

Have patient review Chapter 5 of the workbook and complete the exercises. Instruct patient to continue to use emotion and feelings interventions as indicated. You may wish to assign specific exercises according to the patient’s individual needs.

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Chapter 6

Activity

(Corresponds to chapter 6 of the workbook)

Therapist Note

The number of sessions required to complete this module is determined by the therapist according to the specific needs of the individual patient. An active patient may require only 1–2 sessions, while a patient with activity deficits may require 4–6 sessions. ■ ■

Materials Needed ■

Activity Schedule

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Activity Overview Self-Questionnaire

■

Planning Schedule

■

Self-Questioning Worksheet

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Progressive Muscle Relaxation (PMR) script

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Provide patient with rationale for changing behavior and activity

■

Introduce the Activity Schedule

■

Define the concepts of mastery and pleasure

■

Interpret Activity Schedule data

■

Define and discuss procrastination

Outline

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■

Conduct exercises to understand and change activity level

■

Review other helpful strategies for behavioral activation

■

Introduce and practice different methods of relaxation

■

Assign homework

The behavioral aspect of the BEAST program is often the first intervention in treating the depressed patient. In the assessment stage, the patient’s current and previous level of activity is evaluated. Often, it is discovered that the patient has gradually withdrawn from situations and activities that used to give her pleasure. When asked why they have stopped engaging in pleasurable activities, patients often say they do not “feel” like doing the things they did when they felt better. When depressed people believe in the negative feelings they have about activities, they often do not act and continue to feel bad about what they are not doing in their lives. Research supports the relationship between improved mood and exercise (Byrne & Byrne, 1993; Phillips, Kiernan, & King, 2003). Even one 30-minute run or treadmill exercise has been shown to give the depressed patient emotional relief (Bartholomew et al., 2005). If one trial of exercise can produce a notable change in mood in a depressed group compared to no exercise, it is reasonable to consider that exercise with some regularity will help manage depression. People who exercise report feelings of vigor and well-being.

Rationale for Change Engaging the patient and stimulating her interest in changing her behavior in order to improve her mood is a difficult, but necessary task in treatment. The depressed patient often determines that she needs to “feel” motivated before she can begin changing her behavior and re-engaging in pleasant activities. Because the patient has low mood, however, the “feeling” of motivation doesn’t come, the behavior does not change, and the desperate wait for motivation continues as depression worsens. Redefining motivation to change means that the evaluation of motivation comes after, not before behavior change. Behavior first and 92

motivation second is our new rule ready for testing. Ask the patient, “How do you know it won’t help if you don’t try it first?” The guided empiricism of CBT is about data collection and testing theories associated with mood. Many depressed clients believe that nothing will help, based on beliefs founded in hopelessness. Moods are explained as temporary and activities that help to improve mood can work and will continue to work with repetition (Kritz-Silverstein, Barrett-Connor, & Corbeau, 2001).

Activity Scheduling The Activity Schedule is often a first assignment for the depressed patient. It provides both the therapist and patient a baseline for both the activities the patient pursues during the day and her perception of both mastery and pleasure in what she is doing. Introduce the Activity Schedule and work with the patient to list and rate a couple of activities from the previous week as practice. You may use the following sample dialogue to provide the patient with instructions for completing the schedule: By observing your activities and how you feel when you participate in them, you can find out how often you feel down and what situations are associated with feeling more or less emotionally distressed. Use the Activity Schedule on a daily basis to record the activities you engaged in and the feelings you experienced. By filling in a box for each hour of the day, you can examine what is happening in your daily life and how your activities are related to your mood. Stress to the patient that it is most helpful to record each activity as it occurs. The tendency to report things accurately diminishes as time passes. The sooner the patient records her data, the more reliable the information will be. For example, a person may be grief stricken immediately after a breakup with a significant other. However, with the passage of time and further reflection on the relationship, the individual may later feel fortunate that the relationship did not continue. Encourage the patient to fill out the Activity Schedule daily, preferably on an hourly basis, to avoid the risk of deterioration and/or distortion 93

of memory over time. It can take as little as 5 minutes a day to complete the Activity Schedule. Let the patient consider that not much can be written on the form other than essential shorthand descriptions of activities. For example, a morning description may be best described as “woke up and got ready” rather than describing details of bathroom and dressing habits, with the exception of behaviors and/or events that clearly affect feelings. For example, if the patient gets a disturbing phone call while getting ready for the day, that would be worth noting. However, it is important to caution the patient not to complete the schedule in too minimal a fashion. Although it is best for the patient to use as few words as possible to describe behavior and activity, you do not want the patient to be vague or general. For example, you do not want the patient to write descriptions such as, “did nothing;” “watched TV;” “just sat and thought about things.” These kinds of observations leave out other aspects of what might be associated with mood. Recording some specifics that relate to mood is important to allow the interpretation of the Activity Schedule to be useful. Capturing what else is happening that affects her mood will allow both you and the patient to better consider what you can do next. If the patient returns her first assignment with hard to interpret behaviors, work to draw out more information by asking questions like, “What were you thinking while you were sitting?” or “Was there anything about what you were watching on TV that had an impact on your mood?” The first efforts at activity scheduling give both the therapist and the patient a baseline to compare to as therapy progresses. This baseline can reinforce the effect of potential changes that can occur when the patient engages in self-help assignments. The more data to show evidence of change, the less likely there will be opportunities for the patient to dispute the change with subjective impressions. Stress to the patient the importance of self-observation. Mindful viewing of mood associated with activity lets the patient know how often she feels depressed and what kinds of environments and activities are associated with her mood state. The addition of recording mastery and pleasure ratings for activities creates even more ways to understand the interrelated components of BEAST.

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Mastery and Pleasure Ratings The Activity Schedule includes space for the patient to rate her levels of mastery and pleasure for each activity recorded. Ratings of mastery and pleasure are used to assess how the patient views her behavior and her involvement in daily activities. Each time the patient records her engagement in an activity or event, advise her to also rate her level of mastery (M) and pleasure (P) using a scale of 0–10. Define mastery for the patient as the ability to perform an activity. A score of 10 would indicate that the patient performed the task with exceptional skill. A score of 0 would indicate that the patient did not exhibit any skill at all. Define pleasure as the amount of satisfaction or enjoyment the patient gets from completing a task or activity. A pleasure rating of 10 indicates peak satisfaction. A score of 0 signifies a complete lack of pleasure in the activity. To help the patient understand these concepts, ask her to identify an activity or event she recently experienced and rate it for mastery and pleasure. The event might be something like completing a task at work or communicating with a family member. Engagement is very important in the process of instructing the patient to do homework assignments such as the Activity Schedule, and it may be more likely there will be compliance if there is a realistic rehearsal in session employing the actual recollections of the patient. This can often get the patient engaged in the consideration that they have experienced pleasure in the past even though they are currently depressed. The 0 for pleasure would be the complete lack of pleasure, perhaps seen as the most profound sense of pain or depression. Eliciting such experiences of the worst misery from the patient again allows the person to consider that there have been worse times than now, establishing the sense there is a continuum for the experience of highs and lows. It is also valuable to define the middle, or a 5. That rating is for experiences that are not particularly pleasurable or lacking in pleasure. This would be a score for something that is tolerable. Examples can be elicited here, too, with the idea that what is neutral for some might be more positive or negative for others. An example would be commuting home from work. A low pleasure experience could be the lack of tolerance to traffic and crowds. However,

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if you are used to the commute, you might enjoy the trip home because you can listen to your favorite news program or catch up on phone calls. A 5 for mastery might mean that you are not concerned about your performance as long as the job gets done, such as eating your dinner or finishing a routine job. You may wish to use the following sample dialogue to facilitate a practice exercise: First, name an activity that gives you pleasure but that you still have little mastery in performing. Next, list an activity that you have mastery in but from which you derive little pleasure. Now list an activity in which you have little mastery and little pleasure. Lastly, name an activity for which you experience high levels of both mastery and pleasure.

Interpreting Activity Schedule Data Once there is data, you can begin to help the patient understand and identify problems and work toward making positive change. You can use the patient’s completed Activity Schedule to:

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1.

Assess the patient’s efficiency in her use of time.

2.

Help the patient plan better for more productive activities that are likely to reduce depressive symptoms.

3.

Consider self-enhancement exercises associated with specific instances where self-esteem is affected by activities.

4.

Challenge the patient’s initial idea that she “never” does “anything,” especially if the Activity Schedule clearly shows an engagement in activity.

5.

Demonstrate there are many ways to interpret engagement and outcome for events experienced daily.

Note: Grade activities for Mastery (M) and Pleasure (P) on a scale from 0–10

6−8 a.m.

Monday

M P Tuesday

M P Wednesday

M P Thursday

M P Friday

M P Saturday

M P Sunday

M P

Get up

1

2 Get up

3 2 Get up

4 4 Get up

1

3 2 Sleep

4 4 Sleep

6

6

Eat breakfast

3

1 Eat breakfast

1

3 3 Eat breakfast

3 4 Eat breakfast

3 3 3

1 Eat breakfast

2 Get up

8−10 a.m. Go to work

2 3 Go to work

2 3 Go to work

2 2 Go to work

2 3 Go to work

2 2 Go on a walk

4

6 Take a swim

6

10 a.m.− 12 p.m.

1

2 Meet with client

3 2 Give presentation

2 2 Collect research at library

5 3 Work on hew project

2 2 Go to brunch with friends

4

6 Read the newspaper

5 6

12−2 p.m. Go to lunch

4 5 Go to lunch

5 4 Go to lunch

5

5 5 Go to lunch

3 5 “Weed” the garden

4 2 Meet parents for lunch

3 2

2−4 p.m.

Finish old project

2

2 2 meet with supervisor

2 3 Write proposal

3 3 Work on new project

2 3 Take a nap

5 6 Take a nap

5 6

4−6 p.m.

Go home

4 5 Go home

5 2 Go home

3 2 Go home

1

3 2 Shower and set ready

3 3 Walk the dog

5 7

Eat dinner

5 3 Eat dinner

5 5 Eat dinner

5 2 Eat dinner

5 3 Eat dinner

5

Clean house

3 4 Wash dog

3 3 Go Shopping at the mail

4 6 Go to the gym

2

4 2 Meet friends for dinner

4 5 Eat dinner

4 3

5

2 4 Take hot bubble bath

4 6 Watch TV

3 2 Meet with book club

5 4 Watch TV

3

Work on new project

6−8 p.m.

8−10 p.m. Watch TV

10 p.m.− 12 a.m.

1

1 Go out with friend

Read

2 3

Get ready for bed

4 5 Get ready for bed

2 4 Get ready for bed

4

3 4 Sleep

3 2 Sleep

3 4 Sleep

12−6 a.m. Sleep Week #

6 Training seminar

2 Go to lunch

Date:

6/29/09

Figure 6.1

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Example of completed Activity Schedule

Read 3 Get ready for bed

2 Go home

6 Go grocery shopping

3

3 5

4 Read

3

6

Watch TV

6 5

4 3 Get ready for bed

3 4 Get ready for bed

3 4 Get ready for bed

3 3

2

2 3 Sleep

1

5 4

1 Sleep

2 Sleep

Figure 6.1 is an example of a completed Activity Schedule that can be used to explain the process. Subjective accuracy is an important concept to explain to the patient. A panel of experts is not judging the idiosyncratic interpretation of skill and pleasure. It is the patient’s own sense of experience of events and engagement in events. The patient can challenge subjective accuracy after she produces her assignment. When this is done in collaboration with the therapist, more understanding can be gained about the flexibility the mind can have in perceiving reality. The very fact that there is no real accuracy in subjective judgment can be explained as a way out of the finality of hopeless feelings. If the patient states she is depressed most of the time, she may be operating from an untested theory about herself that does not take situational factors into account. If the patient accepts the theory as fact without examining evidence to test it, she could be sustaining a belief that will keep her depressed. Finding different frames of reference for events is one of the goals associated with mood improvement.

Testing Theory With Observation In addition to using the Activity Schedule to learn more about daily mood patterns, the patient can test her theory of depression by counting the total number of squares she filled in on the Activity Schedule at the end of the week. Before the patient fills out the Activity Schedule, ask her to estimate how much of her weekly activity she thinks she will rate as a 5 or higher in terms of mastery and pleasure. Have the patient record her estimates in the space provided in the workbook. After the patient completes the Activity Schedule, instruct her to count the number of squares, first where the pleasure rating is 5 or above, and second, where the mastery rating is 5 or above. Then, have the patient divide the number of high-pleasure squares by the total number of squares. The result is the percentage of pleasure the patient experienced during the week. Advise the patient to do the same thing with the number of high-mastery squares. Let the patient know that any result obtained will be useful in deciding what to do next in treatment. If the patient finds that she was overly optimistic in her predictions, you can work with her to identify changes

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she can make to improve the amount of satisfaction in her life. This can be accomplished by identifying those environments and activities where the patient experienced more pleasure and mastery and increasing the likelihood of engaging in similar activities in the coming days and weeks. If the patient underestimated the amount of pleasure and mastery she experiences in a week’s time, it can be helpful to examine how depression tends to cloud perceptions. This speaks to bias in thinking and selective perception about recent history. If the patient estimated accurately, this does not mean there is no work to be done. The therapist’s goal is to find utility in any outcome in the analysis of data to allow for future research in an evolving effort to implement methods to improve mood.

Identifying Patterns Associated With Low Mood Another way to harvest utility from the Activity Schedule data is to help the patient to begin identifying recurring events or associations of events that she may not have been aware of before she began recording activities. Refer the patient to the form in Chapter 6 of the workbook which she can use to analyze the information from the Activity Schedule in an effort to identify those situations, environments, activities, and people that have an effect on her mood.

Procrastination Depression, worry, avoidance, and procrastination often go together. When depressed, goal-directed activity tends to diminish compared to premorbid levels. Worry inhibits emotional processing and increases behavioral avoidance when depressed (Borkovec, Ray, & Stöber, 1998). There is evidence that perfectionistic concern over mistakes and doubts about ability in depression is also associated with the tendency to procrastinate (Stöber & Joormann, 2001). Ask the patient if she promised herself or others that she would get to a particular task when she is less depressed. This tendency to “get around to it” can be used to show the patient that now may be the

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best time to do the things she has been putting off. Chronic procrastinators are often labeled as lazy and indolent and stigmatized by others (Ferrari, McCown, & Johnson, 1995). Everything from the serious infraction of not paying taxes to neglecting to send a birthday card usually has eventual painful consequences. Putting decisions and actions off does not always have negative connotations, however, given that there are times when it is wise to defer judgment and avoid impulsiveness. Explain to the patient that every time she decides to do something and then does it, regardless of the skill, that this is a type of mastery. Ellis and Knaus (1979) gave us one of the first cognitive-behavioral definitions of procrastination. They related the phenomenon to irrational fears of criticism and concern for their sense of inability in completing a task properly. The focus here is the concept of inadequacy especially when standards are set too high. The consequences of failure are avoided by never performing the task. In other words, not completing a task is better than completing a task imperfectly. The primary distinction is that the consequences of dysfunctional avoidance are worse than getting the job done without being perfect. A significant decrease in activity has many effects on a person. The patient may rationalize her non-involvement in activities and events by saying that she is avoiding criticism or failure. Perhaps she thinks that she is escaping activities that do not really matter or that are impossible to complete. It is important to investigate the potential consequences of avoiding activities, which often leads to more avoidance and can delay recovery from depression. Research on exercise has shown that it induces enduring and acute changes in brain chemistry neurotransmitters called monoamines, which are linked with mood change Meeusen (2006). Increased action can promote chemical changes in the body that are associated with improved mood. Ask the patient if she has ever wanted to stay in bed all day due to depression. If she answers yes, ask her if she felt better as a result of withdrawing from activity. The more the patient can relate this information about the A in the BEAST, the more likely she might engage in behavior change.

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Understanding and Changing Activity Level Several exercises in the workbook can help the patient understand and change her low level of activity. The first is a series of questions about the patient’s recent behavior. The second is a form the patient can use to plan her daily schedule. The third is a Self-Questioning Worksheet to help overcome avoidance of an activity. Use the information in the following sections to help the patient complete the exercises.

Exercise 1: Activity Overview Self-Questionnaire The first exercise consists of a dozen questions that will help the patient understand and improve her activity level. The questions are as follows: 1.

Are you spending more time in bed each day than you used to?

2.

Have you stopped doing enjoyable things with your family?

3.

Have you stopped doing enjoyable things with your friends?

4.

Do things that used to be pleasant now fall flat for you?

5.

Do you find yourself waiting for the “perfect” time to do something?

6.

Do you find yourself starting projects you do not complete?

7. Do you say to yourself, “It really doesn’t matter” more often? 8.

Do you find yourself just too busy to do things you know are important?

9. Do you find yourself “forgetting” more often than you used to? 10.

Is being a procrastinator a good excuse for not doing anything?

11.

Is your work receiving more criticism than it used to?

12.

Have you been taking less time on your appearance lately?

The preceding questions point to diminished activity level and a lack of pleasure from once enjoyed activities. The lack of activity can be depleting even though the depressed person may assume the opposite.

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Exercise 2: Planning Schedule After examining the patient’s activities and the way they are related to mood, begin working with the patient to plan her days ahead of time. Refer the patient to the Planning Schedule in Chapter 6 of the workbook and help her plan upcoming activities. After the plan for the forthcoming week has been set, the patient should set it aside and go about her daily life. Instruct the patient to review her schedule at the end of each day to see how much pleasure she experienced during the activities she actually engaged in. Advise the patient to complete a schedule for every week. Be sure to remind the patient to bring her completed schedules to every session. The continued use of planning and recording results are methods that the patient can use collaboratively with the therapist to identify and change dysfunctional patterns of behavior. It is important to emphasize the methods will continue to be valuable after therapy is completed to help sustain a better mood.

Exercise 3: Self-Questioning Another method to get activation for avoided activities is the to do or not to do? self-questioning method. Explain this technique to the patient as a way of gaining emotional distance from the avoided action to help promote more reasonable and informed decision making. Direct the patient to the Self-Questioning Worksheet in the workbook and ask her to identify an activity she usually avoids. After identifying an avoided activity, encourage the patient to ask herself what is going through her mind when she thinks about avoiding the particular activity or task. Have the patient record her thought(s) on the worksheet in the column labeled “not to do.” The patient can write down something as simple as, “I don’t want to do this,” or “I don’t feel like it.” The general idea is that avoidance is associated with more basic feelings and simplistic logic and thought that goes unchallenged. Responses in the “To Do” column are less likely to be based on emotion alone. They include evidence, reason, and insight into consequences for avoidance. This method asks the patient to engage her mind in more

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Avoided Activity

To Do

Not to Do

Finish quarterly report for work

I can get fired if I don’t finish it

I don’t feel like it

I will feel good if I submit the report on time

I want to make some calls to my friends

I can watch my TV show another time

I want to watch my TV show

Figure 6.2

Example of Completed Self-Questioning Worksheet

complex processes and identify procrastination as something similar to a regressed state of consciousness. The goal of this exercise is not only to end up on a “to do” statement, but to get the patient to engage in the avoided activity. Figure 6.2 shows a sample completed worksheet.

Other Strategies for Behavioral Activation Recovering Lost Activity The patient may reflect with regret on not doing things she used to enjoy. If her mood is improving, it can be useful to ask the patient to reconsider activities that were pleasurable in the past. You may use the following sample dialogue: What were some of the things that you did for fun last year that you no longer “have time for” or “just can’t seem to get to”? Rate each activity for pleasure on a 0–10 scale. Now, try the same exercise with activities from 3 years ago. Finally, list some of the things you did for fun 5 years ago that you no longer do. Rate these activities for pleasure as well. Ask the patient if there are any realistic reasons that she is no longer engaging in these past activities. For example, the patient may have played cards with friends who no longer live nearby. In this case, perhaps the patient could find others to play cards with, such as coworkers or neighbors. Using creative effort, collaborate with the patient on how

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she can find solutions to what may feel to her like impossible situations. Explain that without examining those situations, it is likely that the unexamined routine of withdrawal will continue.

Risk Taking Often times, depression and fear of change go hand-in-hand. Taking steps to do things that seem risky can be helpful in obtaining a feeling of accomplishment and improving mood. Taking risks for someone who is depressed does not necessarily mean skydiving or quitting a job and joining the military. The risks can be small, like trying a new restaurant or asking a coworker to lunch. Depression is frequently associated with behavioral routines that are constricted. Being depressed can be seen as a competent and welldefended adherence to doing little to improve emotional and behavioral condition. The patient may feel conflicted about letting go of her routine to try out something new. However, getting the patient to challenge old beliefs and go outside of tried and true patterns of boredom and despair is part of the collaboration. Challenge the patient’s resistance by asking questions like, “What are your fears about what could happen?” “How bad can it be if you try?”

Graded Tasks Graded task methods are derived from behavioral shaping strategies. Graded task assignments are commonly used early in therapy to help patients overcome inertia and expose them to potentially rewarding experiences (Butler & Beck, 1995). If a task is overwhelming in size and scope, it is helpful to break it down into smaller, more manageable parts. Many times, a depressed patient can feel overwhelmed and powerless by the effort required to get parts of her life going again. Tasks such as taking care of the home, meeting new people, getting or keeping a job, and other events typical of life are often not addressed or dealt with because problem solving these issues seems complicated and overwhelming.

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Prioritizing Another way to simplify the clutter of being overwhelmed with things to do is to create a continuum. This may involve three lists: Highest priority — things that are more important than anything in the other two lists for completion. These items are done before embarking on less important tasks and endeavors. Medium priority — although important, the items on this list are to be completed only after high-priority items are attended to. Low priority — these items get addressed last, after those on the high and medium priority lists. Low priority tasks are typically what a procrastinator might do first, often based on the fact that the behaviors that are unimportant are what “feel” good or what might be easiest. Consider many of the low priority items a reward for completing the high and medium priority tasks. You might ask the patient if it feels better to eat dessert first, or even more problematic, do you only eat dessert? If you only eat pie and not the salad or main course, what happens to your physical health? If you only do distracting and inconsequential tasks, what happens to your emotional health?

Role-Playing/Behavioral Rehearsal Behavioral activation has been shown to be an effective method for improving mood (Jacobson et al., 1997). Behavioral rehearsal or roleplaying is a technique to help the patient build skills and acts as a potential catalyst by approximating different kinds of avoided activities. The technique can be used to practice potential behaviors or interactions, such as dealing directly with a spouse, a significant other, a boss, or a friend. Your responsibility during rehearsals is to give feedback about the patient’s performance and to coach the patient on more effective responses and response styles. The empty chair technique (Ottersbach, 1992; Smith, 1968) involves the patient speaking to someone as if that person was in the room or in the “empty chair.” Since there is little chance of reaction from the

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empty chair, the patient can consider what the consequences of talking to another might be and look at the imagined consequences on a continuum of possibility. Often, the withdrawn patient will speculate more catastrophic effects. Another way to facilitate behavioral rehearsals is to have the patient portray the role of the friend, parent, or stranger who is reacting to the attempt at dialogue. Both therapist and patient have an opportunity to examine the patient’s reactions and the perceived predictions of responses that may occur from the other person.

Social Skills Training Depression is often associated with an inability to obtain positive reinforcement when in contact with others, which often leads to avoidance of social contact. A social skill is considered a set of behaviors that is positively reinforcing to others (Lewinsohn, Mischel, Chaplin, & Barton, 1980; Segrin, 2000). Lack of social skills can lead to rejection, which can result in the patient withdrawing from activity and an increase in depression. The ability to stir interest from others while in contact with them is a higher-level skill. Depressed individuals may not be able to perform with the ability they had premorbidly. It is also possible that they may never had learned how or had the capacity to communicate in a socially skilled manner. It is common for depressed people to interpret their skills negatively, regardless of the level of competence they possess. Social behavior problems in depression include slow rate of speech, poor eye contact, long pauses and silences, low volume of speech, lack of animation and gestures, flat or blunted expression, and poor eye contact (Segrin, 2000). Also, expressing information inappropriately such as self disclosure and intrusive or ill timed comments that are often negative in nature can distance or repulse others. Learning or reviving social ability and applying the skills are goals that may require you and the patient to be cautious in the predicted outcome. Slight changes for improvement can be highlighted in the collaborative process, especially if the patient had few skills to begin with. Assertiveness training, role-playing, acting or modeling, and experimentation with new or dormant skills can help the patient gain more positive reinforcement associated with improving mood.

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Relaxation, Breathing, and Meditation Depressed individuals often have anxiety and tension. Methods such as progressive muscle relaxation (PMR), meditation, and focused or patterned breathing can relieve many symptoms of anxiety and help regulate a mind and body balance. This can help the patient gain a better sense of control.

Progressive Muscle Relaxation (PMR) PMR methods have been shown to be effective in lowering distressing symptoms in a wide variety of emotional disorders (Carlson & Hoyle, 1993). Explain to the patient that there is a link between muscle tension and depression that she may not be aware of. After introducing PMR, you may wish to conduct an exercise in session. You may use the following instructions to teach the patient an eight-muscle group version of this technique.

Arms Muscle Group

Build up the tension in your arms by making fists and holding your arms out in front of you with your elbows at a 45-degree angle. Notice the sensations of pulling, discomfort, and tightness in your hands, lower arms, and upper arms. Hold the tension. [Pause 10 seconds.] Now release the tension and let your arms and hands relax, with palms facing down. Focus your attention on the sensations of relaxation through your hands, lower arms, and upper arms. As you relax, breathe smoothly and slowly from your abdomen. Each time you exhale, think the word “relax.” [Pause 20 seconds then repeat the muscle group for a second practice]

Legs Muscle Group

Now, build up the tension in your legs by lifting your legs slightly off the floor and, if you feel comfortable, pointing your feet inward. Feel

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the tension as it moves up your feet into your ankles, shins, calves, and thighs. Feel the pulling sensations from the hip down. Hold the tension. [Pause 10 seconds.] Now, release the tension, lowering your legs and relaxing the feet. Feel the warmth and heaviness of relaxation through your feet, lower legs, and upper legs. As you breathe smoothly and slowly, think the word “relax” each time you exhale. [Pause 20 seconds then repeat the muscle group for a second practice.]

Stomach Muscle Group

Now, make your stomach hard by pulling your stomach in toward your spine very tightly. Feel the tightness of your stomach muscles. Focus on that part of your body and hold the tension. [Pause 10 seconds.] Now, let your stomach relax outwards. Let it go further and further. Feel the sense of warmth circulating across your stomach. Feel the soft comfort of relaxation. As you breathe smoothly and slowly, think the word “relax” each time you exhale. [Pause 20 seconds then repeat the muscle group for a second practice.]

Chest Muscle Group

Now, build up the tension around your chest by taking a deep breath and holding it. Your chest is expanded and the muscles are stretched around it. Feel the tension in your chest and back. Hold your breath. [Pause 10 seconds.] Now, slowly, let the air escape and breathe normally, letting the air flow in and out smoothly and easily. Feel the difference as the muscles relax compared with the tension, and think the word “relax” each time you exhale. [Pause 20 seconds then repeat the muscle group for a second practice.]

Shoulders and Upper Back Muscle Group

Pull your shoulder blades back and together. Feel the tension around your shoulders and radiating down into your back. Concentrate on the sensation of tension in this part of your body. [Pause 10 seconds.]

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Now relax your shoulder blades and let them return to a normal position. Focus on the sense of relaxation around your shoulders and across your upper back. Feel the difference in these muscles from the tension. As you breathe smoothly and slowly, think the word “relax” each time you exhale. [Pause 20 seconds then repeat the muscle group for a second practice.]

Neck Muscle Group

Build up the tension around your neck by pulling your chin down toward your chest and raising and tightening your shoulders. Feel the tightness around the back of your neck spreading up into the back of your head. Focus on the tension. [Pause 10 seconds.] Now, release the tension, letting your head rest comfortably and your shoulders droop. Concentrate on the relaxation. Feel the difference from the tension. As you breathe smoothly and slowly, think the word “relax” each time you exhale. [Pause 20 seconds then repeat the muscle group for a second practice.]

Mouth, Jaw, and Throat Muscle Group

Build up the tension around your mouth, jaw, and throat by clenching your teeth and forcing the corners of your mouth back into a forced smile. Feel the tightness and concentrate on the sensations of tension. [Pause 10 seconds.] Then, release the tension, letting your mouth drop open and the muscles around your throat and jaw relax. Concentrate on the difference in the sensations in that part of your body. As you breathe smoothly and slowly, think the word “relax” each time you exhale. [Pause 20 seconds then repeat the muscle group for a second practice.]

Eyes and Forehead Muscle Group

Squeeze your eyes tightly shut while pulling your eyebrows down and toward the center. Feel the tension across your lower forehead and

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around the eyes. Concentrate on the tension. [Pause 10 seconds.] Now release, letting the tension around your eyes slide away. Relax the forehead, smoothing out the wrinkles. Feel the difference of relaxation in comparison to tension. As you breathe smoothly and slowly, think the word “relax” each time you exhale. [Pause 20 seconds then repeat the muscle group for a second practice.]

Patterned Breathing Breathing exercises are getting more support as part of treatment regimen for depression. This is partially due to the revival of interest in Yoga techniques in recent years (Pilkington, Kirkwood, Rampes, & Richardson, 2005). Patients who are willing to explore the abundance of worthwhile classes and trainings in Yoga, meditation, and other relaxation methods are to be encouraged with the caveat that credible instruction should be sought. Yoga that focuses primarily on breathing is Pranayama which means “control of breath.” Patterned breathing involves learning to breathe according to a rhythmic model of inhalation, holding, and exhalation, such as a square or rectangle, or according to a slower rhythm. The patient can imagine a figure and breathe in through the nose at a count of 2 or 3. The breath is then held for a similar count. This is followed by relaxed exhalation through the mouth at a count of 3 or 4, followed again by holding breath for a count of 2 or 3. The pattern can be done 10 times. The slow rhythm serves to stop hyperventilation.

Meditation Meditation involves methods that are covered in the “thought” component of the TTB program (See Chapter 8). It is paradoxically learning non-doing. Doing nothing is not the same as non-doing in the process of meditation (Kabat-Zinn, 1994). The term “doing nothing” is viewed by some as wasting time. Non-doing is a pause or incubation period that allows for rest before activity. It potentially restores energy and makes active doing more efficient.

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Meditation is an intentional method of shifting attention in such a way that increased awareness, reduction of stress, and a sense of self-acceptance and well-being can potentially occur.

Homework

✎ ✎ ✎ ✎ ✎ ✎

Have patient review Chapter 6 of the workbook and complete the exercises. Instruct the patient to keep the Activity Schedule on a daily basis. Instruct the patient to use the Planning Schedule. Have the patient complete the Self-Questioning Worksheet if procrastination is a problem. Encourage patient to try other strategies for improving activity level as appropriate. Advise the patient to practice relaxation and stress reduction techniques such as patterned breathing, progressive muscle relaxation, and meditation to relieve anxiety and tension.

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Chapter 7

Life Situations and Vulnerability

(Corresponds to chapter 7 of the workbook)

Therapist Note

The number of sessions required to complete this module is determined by the therapist according to the specific needs of the individual patient. ■ ■

Materials Needed ■

Vulnerability Factor Worksheet

■

Vulnerability Threshold Worksheet

■

Coping With Stressors Worksheet

■

Define and explain the relationship between emotions and life circumstances

■

Work to motivate the patient to change

■

Address the unspoken part of life situations

■

Identify specific and non-specific stressors for the patient

■

Discuss vulnerability factors and how they impact depression

■

Evaluate situation-specific vulnerability

■

Help patient develop a plan for coping with difficult life situations

Outline

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■

Teach the patient how to evaluate and prioritize stressors

■

Assign homework

Understanding Life Events Individuals are often affected by events over which they perceive they have little or no control. Situations happen, to paraphrase a bumper sticker. For example, a person may be diagnosed with a serious illness that he may or may not feel he had any control over. In a case of job loss, although a person may have exhibited behaviors that led to the loss, he may feel he should have been treated differently or had remedial action taken before he was fired. Another may lose a loved one who did not understand him or give him another chance. Situations in their lives are often linked to beliefs that affect emotional equilibrium. Individuals literally feel “off-balance.” These underlying beliefs, called schema, may prepare individuals for some situations and not for others (Freeman & Freeman, 2005a). For example, the belief systems may have worked for family issues but do not work for the community at large because the family they were created for does not operate by general community “rules.” A person who lives life believing that there is danger everywhere misses out on many of the fun and enjoyable social experiences that give pleasure to other individuals and therefore is vulnerable to depression. However, that same individual is safe if he lives in an unsafe neighborhood or a war zone. For most, these schema are extremely stressful. If an individual believes that “nothing good will ever happen to me” he will avoid disappointment, however, he will also miss out on many other meaningful experiences (Freeman & Freeman, 2005a). These beliefs are often associated with depressed thinking and, therefore, depressed mood. The thinking style makes it difficult for these individuals to recognize when a positive life event occurs and enjoy it appropriately for the occasion. Personality can adversely affect the way an individual understands or views situations. Individuals with personality disorders can exhaust, frustrate, and even anger people around

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them, leaving themselves alone, angry, and suspicious of others in general. In addition, these individuals often lack understanding or insight as to the part they might have played in their own misery (Freeman & Rustagi, 2008). Individuals who live in safe environments, both socially and physically, may develop these types of thinking errors that seem to occur automatically regardless of their appropriateness to the situation. The automatic thinking errors create negative emotions, discomfort, and additional thinking errors that reinforce the belief that they are correct in their negative assumptions. In this module, the individual will find ways to identify situations accurately and change the automatic thoughts about the situations that get in the way of happiness and fulfillment. It is important to remember that these exercises are part of a change process and all of the negative thoughts will not go away immediately. Practicing the skills will slowly reverse the old habits of thinking until new habits are formed. Practicing the change skills in automatic thoughts with a situation will help patients get through difficult times by adjusting their thoughts. Research has shown that using the skills outlined in the following sections is effective in reducing episodes of depression, relapses of depression, and when combined with medication are more effective than medication alone (Beevers & Miller, 2005; Bockting et al., 2005). The more times a patient practices the skills, the more skilled the patient will become with each skill set.

The Value of Change When working with individuals with depressive disorders, you are well advised to have a clear, strong, reasonable, and realistic idea and image of what the desired outcome will look like. If you don’t, treatment may falter and the patient’s improvement will become illusive. Collaborating with the patient to outline what the “finished product” will look like, act like, and sound like, consensus between patient and therapist is an important step in treatment. An essential goal of therapeutic change is to provide the patient with a motivation to change. This includes making the commitment, making the effort, spending the time, spending the

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money, disrupting (and possibly upsetting) significant others, and risk the anxiety of being “different.”

The Unspoken Part of Life Situations In this section, you will teach the patient how to identify and utilize skills related to surprises, daily problems, crisis, and even rewards of daily life. Stressors include both positive and negative life events. A positive life event may include additional stressors. For example, buying a new car brings with it the added responsibility of getting insurance, making payments, and being a more careful driver. An increase in pay may mean additional responsibilities or a move to a new apartment or home, which also causes increased stress. Depending on how the patient views these changes, the positive life event may become a negative life event fraught with stress and negativity. Therefore, it is not the experience or situation itself that is the stressor but the patient’s internal perception of the experience or situation. As Shakespeare’s Hamlet once said, “There is no good or bad, but thinking makes it so.” The following list contains spoken statements followed by unspoken assumptions. As you can see, a negative life-view leads to unspoken assumptions that magnify bad situations. Statement “I was just fired!” “My mother died yesterday” “I am always in such horrible pain”

“My wife left me”

Assumption (I will never find another job!) (I am all alone now) (I can not live like this!) “I look in the mirror and I see an old woman” (I am at the end of my life and it has passed me by) (I cannot live without her)

For a person who has a different life-view of his situations, the cognitive and emotional results would be very different (see the following revised statement list).

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Statement

Assumption “I was just fired!” (I am going to start looking for a job where they appreciate me!) “My mother died yesterday” (She is finally at rest after being so sick for so long) “I am always in such horrible pain” (I am glad that it doesn’t prevent me from walking and seeing me grandkids!) “I look in the mirror and I see an old woman” (I am so happy I lived long enough to reach this age!) “My wife left me” (I need to learn from this experience and decide if I want to seek a more compatible mate)

Certain life events are indisputably negative. Consider heart attacks or other cardiovascular events for example. As many as 30% of individuals develop depression after experiencing a heart attack (Wann, Bah, Boucher, & Courtemanch, 2007). However, of those who experience depression and are treated with cognitive behavior therapy, more than half (57%) are much more likely to experience remission than those who go untreated (43%) (Strachowski et al., 2007). Most life situations are time-limited and specific to that situation. We recommend that you help your patient pull from other areas of his life to learn to view his own situations in different ways. It is possible to create meaning from such situations no matter how catastrophic they may seem. If an individual is feeling blue, depressed, or down he may feel like the weight of the world is on his shoulders. The first goal in this situation is to identify the things the patient has to deal with. Once the list is completed, items can be prioritized. Help the patient notice that there are probably only five or six things at most that require immediate attention. Explain to the patient that sometimes even one stressor can feel overwhelming, especially if there are co-existing stressors already in place. The goal is to make each of the stressful situations more manageable and less damaging, or “weighty.”

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Identifying Stressors Use the following information to help the patient identify his personal stressors. Stressors are divided into two groups: specific and non-specific. Work with the patient to identify specific stressors first. These may include events such as losing a job, the death of a loved one, or the breakup of a relationship. For some individuals, specific stressors may not be as dramatic or catastrophic as they may be for others, but are felt just as acutely. Their lists may include the rising costs of living, the inability to move south with their friends as they retire, fears about what the job market may look like after graduation, and so forth. Have the patient list the specific stressors that are currently contributing to his depression in the space provided in the workbook. Next, help the patient identify his non-specific stressors. This list is usually precipitated by a traumatic event or a series of events, each in itself rather small. In combination, the events add up to a stressor that contributes to depression. An example might be getting caught in traffic resulting in the patient being late for a meeting at his child’s school. Another example might be a cough that doesn’t go away resulting in the need to schedule a series of medical tests that require asking for time off from work that requires the patient to submit paperwork and respond to questions from their boss and human resources about excessive time off. Ask the patient to use the form provided in the workbook to identify his non-specific stressors.

Vulnerability Factors Vulnerability factors increase the likelihood that an individual will be negatively affected by life situations, will be more sensitive to even small situational changes, or more reactive. These factors may cause the patient to overlook options for coping effectively and instead simply react to the situation using old habits of thinking and coping. The older habits and automatic responses increase the likelihood that that there will be a depressogenic outcome. Following is a list of common vulnerability factors. Review this list with the patient (a copy is also provided in the workbook) and check to see if there are other factors that are not

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included on this list. Ask the patient to identify the factor(s) that may apply to him and note these on the Vulnerability Factor Worksheet in the workbook. 1.

Acute Illness: When you are ill, your ability to cope with life stress decreases. Illness can range from the severe and disabling to more transient health problems such as common colds, headaches, and viral infections. It is essential for the patient to consult with his primary care physician so that illnesses can be dealt with medically. Many medical illnesses contribute to physical symptoms that mimic depressive disorders or contribute to prolonged recovery from depression.

2.

Chronic illness: In addition to acute illness, situations in which the health problem is chronic can lead to increased severity of suicidal thinking.

3. Deterioration of health: In aging, there may be a loss of activity because the body cannot perform up to the expectations that were appropriate at other times in life. 4.

Hunger: During times of food deprivation, individuals are more vulnerable to a variety of stimuli. Hunger can lead to low blood sugar which can cause headache, fatigue, and irritability as well.

5.

Anger/frustration: When an individual is angry or frustrated, he loses the ability to problem solve appropriately. There is a higher probability that an angry person will make impulsive decisions or say things to hurt someone else’s feelings which he will then feel bad about later. Anger creates a greater sensitivity to stimuli in general with a decreased ability to listen to others effectively (Ziegler & Smith, 2004).

6.

Fatigue: In a similar fashion, fatigue also decreases a person’s ability to problem solve and control impulses. People who are tired often mistake fatigue for a symptom of depression. Chronic fatigue might indicate a medical issue that requires attention (Rupke, Blecke, & Renfrow, 2006).

7. Loneliness: When a person is lonely, he may begin a cycle of negative thinking that includes reduced options for himself or

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even decreased self-care. Loneliness may be accompanied by thoughts such as, “no one cares about me” and “I would be better off dead” as the negative thoughts spiral downward. 8.

Major Life Loss: Major losses, especially of loved ones, may increase negative thoughts that include reduced life options and conclusions such as, “I don’t care what happens to me” or “I can’t believe that this happened to me, I can’t live like this anymore.” An individual with few outside interests is particularly vulnerable to loss (Gilson, 1992).

9. Limited problem-solving ability: Some individuals have chronic difficulties with problem solving in general. This creates stress anytime that they are faced with a new stressor that is beyond their capability to manage or control. For these patients the issue is complex: self-esteem problems related to their limited abilities compared to others as well as their difficulty responding to stressors.

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10.

Substance use: Mood-altering substances increase both anxiety and depression as both primary and secondary effects of the substances themselves. The use of substances, including caffeine will significantly lower an individual’s threshold of vulnerability. Chronic use creates damage to the memory areas of the brain, as well as judgment and impulse control areas.

11.

Chronic pain: This is one of the most common factors that lower the vulnerability threshold if the patient does not have alternative interests and a positive mind-set to cope with this issue. The effects of chronic pain range from discomfort to a general negative view of the future to complete hopelessness. Many experience anger and even a sense of betrayal by the medical community with a sense of mistrust of all health care providers (Freeman, 2007).

12.

Acute pain: Acute pain refers to “short-term” pain. Acute pain can be a significant vulnerability factor for someone who does not handle incapacitation well. Surgery, a broken leg, or other pain-related situation causes not only extreme discomfort, but is

accompanied by the inconveniences associated with not being in control. 13.

Impulse control problems: Individuals who have difficulty controlling their impulses often find themselves either “cleaning up” after themselves or in a crisis as a result of their loss of control. An example is the individual who can’t resist a sale, one after another, and exceeds his limits on his credit cards, placing himself in financial crisis. Another example is the individual who say or do things that are considered socially inappropriate or rude and has now lost his friend.

14.

New life situation: A new life situation may be positive or negative. Divorce, marriage, job loss, job promotion, new baby, children moving away, moving to a new city, winning a lottery, bankruptcy, etc. can all serve to lower thresholds and increase vulnerability. The therapist must keep in mind it is not the situation itself, it is how the patient views the situation that is the defining factor.

Evaluating Situation-Specific Vulnerability Certain factors can lower the patient’s threshold for vulnerability and expose him to stress and other stimuli that contribute to depression. Sometimes these vulnerability factors are specific to certain situations. The next section will identify common situation-specific life areas that are problematic for many individuals. Using a rating scale of 1–100, have the patient evaluate how much difficulty he has managing his stress in each of the vulnerability areas. Use a “T” to indicate threshold. For example, if it takes very little of a particular factor to affect the patient, then he is susceptible to that vulnerability factor. That would indicate he has a low threshold (1). However, if it takes a great deal of stress in that particular area to affect the patient, then he has a high threshold (100) in that particular area. Direct the patient to the Vulnerability Threshold Worksheet in the workbook. The patient will use this form throughout the course of treatment to evaluate his change in vulnerability to certain life factors. The patient may make photocopies of the worksheet or use different colored markers to track changes on one form. There are blank

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spaces at the bottom of the worksheet for the patient to add other life areas that are not already listed. Allow the patient to complete the worksheet in session and review the data together. The patient can now notice that his vulnerability thresholds differ depending on the life event. Review each area listed and ask the patient to identify his current level of stress for each by placing an “S” on each line. For example, if the patient rated his stress in “Dealing with my parents” at a 50 threshold, but his actual stress level is a 40, he doesn’t have far to go before he gets overwhelmed. However, if the patient rates his actual stress at a 15 and his threshold at a 50, he can tolerate quite a bit before becoming overwhelmed. When the patient’s stress increases in one or more areas over his threshold, or more stressors occur, the patient is at greater risk for depression.

Coping With Difficult Life Situations One of the guarantees we can make to our patients in treatment is that they will experience a crisis, they will experience a significant loss, and they will be seriously disappointed. Therefore, it is important to begin planning how the patient is going to deal with it before it happens, not after it happens. Refer to the patient’s completed Vulnerability Threshold Worksheet and work with him to develop a plan for handling those situations where his amount of stress exceeds his threshold. Direct the patient to the set of questions in Chapter 7 of the workbook. These questions will help guide the patient in problem solving and developing realistic coping techniques for dealing with life stressors. The two sets of questions differ only slightly in their wording. Help the patient evaluate the differences between the sets of questions and how the patient “thinks” differently after responding to the questions. Set I:

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Can someone else handle this for you?

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Can you postpone the situation?

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Have you dealt with situations like this before?

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Do you know anyone who has dealt with this situation before?

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Can you change parts of the situation?

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Is the situation going to change with time?

Set II: ■

Is it possible that you do not have to deal with all of the situation by yourself?

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Is it possible to postpone a small part of the situation?

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Have you dealt with slightly similar situations?

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Do you know anyone who has ever had to deal with anything like this before?

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Is it possible that parts of the situation are more easily changeable?

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Is it possible that the situation going to change with time?

Review with the patient the “yes” responses between the first and the second set of questions. If there is a difference, discuss the differences. The first set of questions is phrased in ways that give little chance of change and therefore are more “all-or-nothing” in their thinking style. In the second set of questions, the questions are phrased in such a way as to promote the possibility of change and therefore require more flexibility in thinking. All-or-nothing thinking is one of the many thinking errors or distorted thinking styles that result in negative outcome views for individuals. More information on cognitive errors is provided in Chapter 8. The previous exercise is one step in the process of enhancing the scope of possibilities in coping with external stressors. Each time an individual achieves success where he has not experienced success in the past, hope is possible. As more steps are taken and successfully mastered, the individual gains more confidence that he can overcome larger and larger obstacles.

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Example: Define task: Clean my room Goal/Reward Finish task Dust furniture Vacuum Pick up clothes Begin task

Make bed

Define goal: Have room looking neater and more orderly

Figure 7.1

Example of Completed Coping With Stressors Worksheet

In the session, have the patient choose one specific and reasonable stressor that he is likely to successfully overcome. Have the patient answer the second set of questions about that stressor. Next, have the patient write down one small part of the stressor situation that he can start working on coping with. After that is “defeated” choose another part of the stressor, and then another, and so on. The Coping With Stressors Worksheet in the workbook may help assist the patient in visualizing change as a series of steps that are mastered one at a time. Figure 7.1 shows a sample completed worksheet.

Prioritizing Stressors Many times when patients are feeling overwhelmed it is due to the perception that they have to continue to meet all of their usual deadlines, priorities, and needs in addition to dealing with the new stressor. This last section addresses the strategy for stress reduction when these types of situations occur. Basically, it simply requires that the patient break down the seemingly overwhelming situation into its component parts and evaluate the component parts using the checklist of questions from the previous section. Alternatively, the patient can list his competing priorities and use the same strategy. Initially, the patient may need to do this in session with your help in order to problem solve priorities that

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can be set aside (“I have a haircut at 2 p.m. tomorrow”) and priorities that can be delegated to other family members (clean the litter box). Here is an example of a situation where a patient required assistance prioritizing stressors. Sheryl was in the middle of exam week. She was overwhelmed because she had so many things to do. There was a sorority meeting tomorrow and a party at the end of exam week and she wanted to go to. She said that it was important to get new clothes. There were emails from her friends that she had not answered yet. She and her roommate were going to fix up the room since it was so messy. A new guy she really liked left her a text message to call him. She was spinning when she came into the session. She did not know what to do first. Sheryl’s therapist asked her to go to the board in the room and take a marker and divide the board into three parts. First part was designated things that were of highest importance, the second part was of some importance, and the last part was of minimal importance for this week. When she was expressing being overwhelmed, her therapist suggested she breath slowly from her diaphragm and try and soothe herself. When she said she was ready, the next question the therapist asked was why she was in school. Sheryl said that it was to get an education. She was asked that if that was the case, what would go into the high priority list? Sheryl said to study and do well on her tests. She then wrote that on the board in the high priority column. Now her task was to see where the other situational concerns would go on this three-part list. If studying was the most important, then were other perceived demands of her time worth concentrating on this week with the same urgency? She did not think so when she considered what they were. So where do they go? She decided that cleaning the apartment was in the low priority list and could be done next week. She then saw the demand to answer emails somewhere in the middle. She drafted an email to send to all her friends who were writing her that she would not be answering until after exams. The text message from the guy she liked was still viewed by her as important. He was really good looking and she had hoped he would take an interest. When questioned how important, she somewhat reluctantly put him after her studies. She

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determined that she would call him and ask if they could talk after exams. As much as she loved to shop for new clothes for the party, she decided she had something she could wear and ranked that concern at the third column of her priority list. If she did well on her exams, she would reward herself by getting new clothes. As far as her sorority was concerned, she put that in the middle list and that she would attend only if she met a goal for her studies on that day. She was asked what the consequences of being absent from the meeting were? Sheryl remarked doing poorly on exams would be more devastating than any snippy remarks her sorority sisters may have if she did not attend the meeting. Her desire to go to the meeting was then to be used as motivation to get studying done sooner rather than later. Sheryl left the session encouraged that she would be able to handle her situation this week and not let every possible interest or distraction get in the way of her important goals of doing well in her studies.

Homework

✎ ✎ ✎ ✎ ✎

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Have patient review Chapter 7 of the workbook and complete the exercises. Have patient complete the Vulnerability Factor Worksheet. Have patient complete the Vulnerability Threshold Worksheet. Have patient identify a distressing situation and complete the Coping With Stressors Worksheet. Ask patient to create a priority list of tasks to better manage the circumstances that are causing distress.

Chapter 8

Thoughts

(Corresponds to chapter 8 of the workbook)

Therapist Note

The number of sessions required to complete this module is determined by the therapist according to the specific needs of the individual patient. ■ ■

Materials Needed ■

Automatic Thought Record (ATR)

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Define and discuss the cognitive triad

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Work with the patient to identify cognitive errors

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Teach the patient different methods for challenging negative, automatic thoughts (ATs)

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Introduce the Automatic Thought Record (ATR)

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Discuss mindfulness and meditation

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Assign homework

Outline

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The Cognitive Triad The cognitive triad is a summary model of the components of depression, first introduced in the landmark book Cognitive Therapy of Depression (Beck, Rush, Shaw, & Emery, 1979). The triad describes the three negative views that characterize depression. The first is the negative view the patient has about herself (self-concept, self-view). The second is the negative view the patient may have about the world or her experience in it (environment, surroundings, and circumstances). The third is the negative view the patient may have about her future (what is next, lack of hope). The negative perception of these components is what sustains depressed mood. The concept of the triad is presented to the patient to help her start to divide the global experience of depression into smaller, more manageable pieces. Each view is characterized by thoughts that reflect that view. The thoughts about self are explained to the patient as those self-talk sentences that include a personal pronoun such as I, me, or my. Negative thoughts about self may include the following: ■

“I am no good.”

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“Nobody likes me.”

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“My work is terrible.”

The experience of the world or personal environment is the second component of the triad that can have a negative bias with depression. Ask the patient how she is experiencing things around her. Negative thoughts about the environment may include the following: ■

“Life is unfair.”

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“People should be nicer.”

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“The government is corrupt.”

Finally, there are negative thoughts about the future. Examples include:

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“My life will keep getting worse.”

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“The world is going to destroy itself.”

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“There is no reason to live.”

Therapist Note

The last thought in the preceding list speaks to the seriousness of this part of the triad. Suicide attempts are often associated with hopelessness. It is extremely important to evaluate suicidal ideation in your patient at the beginning of treatment and to take steps to help the patient stay safe if she is experiencing thoughts of suicide or self-harm. ■

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Many of life’s problems can be categorized into at least one of these three categories of negative views. The accumulated content in each of these views provides evidence in how the world is seen overall. This approach to therapy looks at how emotions and feelings typically correspond with the negative content of the three views. An example you can give to your patient is that of a person who views herself as unattractive who therefore avoids situations in which physical attractiveness may be seen as a prerequisite for success (dating, public speaking, etc.)

Negative View of Self Ask the patient to write down any irrational or negative thoughts she has about herself in the space provided in Chapter 8 of the workbook. Examples include negative self-statements such as “I am stupid,” or “I never do anything right.” This is often a very simple exercise because the patient automatically generates these self-identifiers spontaneously during the interview or while telling the therapist about an experience. As the individual is spontaneously talking, you may wish to write down verbatim negative identifiers in the margins of your paper and capture any irrational statements as well. These become “in vivo” grist for the therapy mill. Explain to the patient that such negative statements tend to be global and seem to come automatically. Instruct the patient to simply write what comes to mind so it will be possible for both of you to get a look at the habitual negative thoughts about self that cross her mind.

Negative View of the World Next, ask the patient to write down the negative thoughts she has about the world and her experiences within it. Ask her: “What thoughts do

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you carry with you about what is going on around you?” Again, caution the patient not to stop and analyze whether the statements are true. Often times, paradoxically requesting the patient not to analyze may internally invoke a desire to question the thoughts, given that you are helping the patient get distance from the factors in thinking that are associated with depression.

Negative View of the Future Inquire how the patient sees the future or even the rest of her life. Does she focus on the idea that “things will always be this bad”? Does she predict negative results for things she might try to do in the future? Have the patient write down any specific negative thoughts she has about the future in the workbook. Let the patient review the groups of statements that she has recorded to determine the degree to which her thoughts fit the cognitive triad model of depression. It is important to structure the program for relieving depression first by paying special attention to the areas in which thoughts are most negative. Personal issues relating to self, world, and future are different for each individual. Each part of the triad does not necessarily contribute equally to the experience of depression. By assessing the relative contribution of each of the three components, the patient can begin to develop a clear understanding of her unique combination of negative thoughts. You can suggest to the patient that doubt is an important component in CBT and that she might consider not “trusting everything she thinks,” especially if it is associated with depression. Underlying assumptions, core beliefs, and schema are terms used to describe the possible anchors to the patterns of automatic thoughts that occur in the most recalcitrant of mood problems and in personality disorders. They are often outside the scope of shorter term therapies. In her book Cognitive Therapy for Challenging Problems (Beck, 2005), Judith Beck describes core beliefs as ideas, not truths. Often times, these beliefs are described as feelings such as “I feel no one can love me,” or “I feel I can never succeed.” These schemas are often the result of early experiences. The interpretation of those early experiences may or may not be accurate and of course cannot be verified. However, they may

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be perceived as fundamental by some patients. The coping strategies that were used in the past are usually not valid in current circumstances. Challenging these beliefs is important. However, many with mild or moderate depression do achieve their goals of improvement with the application of cognitive methods in the short-term format that we describe. Those patients with diagnosable personality disorders will probably require more time and extra strategies to gain lasting improvement. Assessing each group of negative thoughts will help you personalize the therapy program to the patient’s specific areas of concern rather than toward vague, global problems.

Cognitive Distortions Distortions represent biased views that are not as a whole validated by other people. They represent a selectively narrow part of experience, usually negative in depressed thought. Distortions in thinking are frequently the initial focus of therapy because they are often easily identified. Beck’s (1963) early writing on the topic stated the typical ideational content of depressed patients was characterized by themes of low self-esteem, self-blame, overwhelming responsibilities, and desires to escape. It is important for the patient to discover the distortions in her thinking by tracking “automatic thoughts”—those spontaneous thoughts associated with certain moods and/or situations. These spontaneously generated thoughts can then be evaluated for the impact they have. Recognizing these distortions and biases can point to underlying patterns in thinking. The main purpose of discovering distortions is to allow the patient to begin to alter dysfunctional thoughts and thought patterns. Help the patient understand that everyone experiences dysfunctional or irrational thoughts to some degree. Many people may be biased because subjective personal experience influences perceptions. These biases become problematic when they are too extreme or are inappropriately relied upon. Depression may allow for a degree of accuracy of negative information, but the narrowness of perception can often leave out valuable aspects of the world and self. The following are examples of types of biased or distorted thinking. Refer the patient to the same information in the workbook.

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1.

All-or-nothing thinking: considering only extreme options, seeing things in black or white with no shades of gray. ■ ■ ■

2.

I am either a success or a failure. Things are either completely right or absolutely wrong. I love you or I hate you.

Mind reading: assuming that you know what others are thinking. ■ ■ ■

They probably think I am incompetent. I just know that she disapproves. Even though people do not say so, I know how they really feel.

3. Emotional reasoning: the belief that if you feel something, it must be true and should be acted upon. ■ ■ ■

4.

Personalization: the belief that you are the target of difficulty. ■

■ ■

5.

That comment was not just random; it must have been directed at me. Problems always emerge when I am in a hurry. Someone is always picking on me.

Overgeneralization: assuming that one incident applies to all others. ■ ■ ■

6.

I feel so inadequate, I must be inadequate. I feel so angry, I must express it. If I feel anxious, I should not go out.

Everything I do turns out wrong. It does not matter what my choices are; they always fall flat. My boyfriend broke up with me; no one wants me.

Catastrophizing: assuming the worst. ■ ■ ■

If I go to the party, there will be terrible consequences. I better not try because I might fail, and I could not stand that. My fiancé broke our engagement; I will never get married.

7. “Should” statements: reflect a judgmental attitude. ■

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I should visit my family every time they want me to.

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8.

They should be nicer to me. I should not feel angry [or scared or anxious].

Need for control: the belief that absolute control at all times is necessary. ■

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If I am not in complete control all the time, I am in danger of going out of control. I must be able to control everything in my life. I cannot let anyone else help me with this task. They might do it wrong.

9. Negative comparisons: viewing your performance negatively in comparison to others. ■ ■

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10.

Disqualifying the positive: difficulty believing positive experience. ■ ■ ■

11.

This success experience was only a fluke. That compliment was unwarranted. Even though she said she liked my work, I know she did not mean it.

Perfectionism: the need to be perfect. ■

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12.

I am not as competent as my co-workers or supervisors. Compared with others, there is clearly something flawed about me. Even though it is OK for other people to make mistakes, it is not OK for me to.

If I cannot do everything perfectly, I will be criticized and feel like a failure. Doing merely an adequate job is akin to being a failure. When I make a mistake, I feel worthless.

Selective abstraction: missing the big picture. ■

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All those compliments do not matter. This criticism is the only thing that matters. I seem to dwell on the negative details and don’t pay attention to the positive aspects of a situation.

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13.

Externalization of self-worth: looking to others for self-validation. ■ ■ ■

14.

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Life should be fair. People should be fair. Good behavior should always be rewarded.

I must be right: rigidly maintaining that one is right in all circumstances, despite contrary evidence. ■ ■ ■

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If I ignore it, maybe it will go away. If I do not pay attention, I will not be held responsible. What I don’t know won’t hurt me.

Fairness: the belief that life should always work out the way you think it should. ■

18.

If I think about it long enough, it will be resolved. One cannot be too concerned. If I forget to worry or let down my guard, something bad might happen.

If I ignore it: avoidance as a defense. ■

17.

If only my situation were different, all of my problems would. . . If only I were taller, she would like me. If only I had not (e.g., made that decision, done that), I would be happy now.

Worry helps: believing that worrying equates with protection. ■

16.

My worth is dependent upon what others think of me. They think I am (e.g., stupid, lazy); they must be right. I am not OK unless I am pleasing others.

If-only thinking: wishful or regretful thinking. ■

15.

Even though I received an overall positive review, I think that I am not doing a good job.

I must prove that I am right; being wrong is unacceptable. To be wrong is to be unforgivable or a bad person. If I am wrong about one thing, it means I am wrong about everything.

19.

I can’t stand it: the belief that a specific situation or feeling is intolerable. ■ ■ ■

20.

I cannot stand to be angry without exploding. I cannot stand not knowing if he or she loves me; I must ask. If I experience happiness, something horrible will happen.

I can’t live without . . . : the belief that life is not worth living if a desire is unattainable. ■ ■ ■

I cannot live without a man/woman. If I were in a relationship, all my problems would be solved. I cannot survive if I am alone.

Ask the patient to review the list of cognitive distortions in the workbook and circle those she is most likely to experience and give examples of her own thoughts. Suggest to the patient that she come back to this exercise later to add distortions because these thoughts may occur automatically and be embedded in other thinking to the extent that they are difficult to recognize.

Challenging Cognitive Patterns Cognitive techniques are useful in challenging biased, distorted, and negative thinking patterns. This section lists such techniques and explains their purposes. It is helpful to impress upon the patient the importance of not accepting feelings over reason. The goal is to help the patient question her thoughts. It can be precarious only to trust feelings when making a decision or judgment and it can also be a problem if feelings are not considered. Cognitive therapy attempts to help the patient effectively integrate a balance of feeling and reason. We have used the term “depressed you” to indicate the patient’s emotional state. Explain the “depressed you” as how the patient feels when she has a negative experience. Define the “challenger” as the internal questioner who is going to examine, understand, restructure, and possibly dispute the thoughts associated with depression. The challenger is characterized as the patient’s therapist within the self, used to widen perspective and allow response to the evidence they may not be attending to.

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Table 8.1 Cognitive Techniques 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Questioning what you really mean Questioning the evidence Reattribution Examining options and alternatives Decatastrophizing Examining expected consequences Listing advantages and disadvantages Turning adversity to advantage Labeling distortions Guided association and discovery Using paradox or exaggeration Scaling Replacement imagery Cognitive rehearsal Self-instruction or coaching Thought stopping Focusing Self-compassion Is it signal or noise?

There are a number of techniques you can use with the patient to facilitate cognitive restructuring. See Table 8.1 for a list of these techniques. The following sections briefly describe each of these techniques and provide instructions for engaging the patient in cognitive restructuring exercises.

Questioning What You Really Mean Suggest to the patient that she may not completely understand the terms she is using to define her depression. If you asked a group of 10 people to describe depression, you would likely get 10 different responses. Descriptions might include words like sadness, the blues, hopelessness, sleep difficulties, sluggishness, slowed thinking, pessimism, and apathy. Given the varying meanings that words have, it is essential to question exactly what the patient means when she uses certain words.

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Have the patient list some of the negative words she uses to describe herself in the space provided in the workbook. Then, ask the patient to go back and challenge each word to determine what it really means to her. See the following example: Word I Use to Describe Myself Loser

Challenge the Word ?

What Do I Really Mean? I make many mistakes.

In instances where the meaning of these words is negative, have the patient go back and ask if there is evidence to support her self-defeating opinion. More can be learned about this technique in the next exercise.

Questioning the Evidence One effective way to challenge a dysfunctional thought is to examine the extent to which the thought is supported by available evidence. Have the patient ask if other interpretations are more reasonable. It is essential to teach the “depressed you” to question the evidence that used to maintain and strengthen an idea or belief. When selective abstraction is used, the patient may ignore major pieces of data and focus on the few aspects that support depressive views. By questioning the evidence, it can broaden focus to include the entire reality rather than just the narrowly focused negative view. Even the slightest doubt in the initial, fixed belief could be the first step toward meaningful progress. To facilitate this exercise, ask the patient to select three negative assumptions she has about herself and life in general. Have her list them in the space provided in the workbook. Then, instruct the patient to go back and challenge the evidence for each assumption.

Reattribution A common statement from individuals who are depressed is “It’s all my fault,” especially in situations of relationship difficulty. Some individuals take total responsibility for situations; others tend to blame someone else and take no responsibility whatsoever. By becoming a “challenger,”

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the patient is invited to begin distributing responsibility in a more realistic and accurate manner. Taking the middle ground can help the “depressed you” reattribute responsibility and not take all the blame or unrealistically shift all the blame to someone else. Ask the patient to list negative events or circumstances for which she feels totally responsible for. Then, instruct the patient to go back and ask herself if anyone else besides her may have shared in the responsibility. The purpose of this exercise is not to shift blame entirely from the patient to someone else, but rather to reveal the fact that many circumstances are associated with a combination of people and events.

Examining Options and Alternatives People who are suicidal see themselves as having lost all hope. Death might be the easiest choice. Thoughts of suicide represent a profound difficulty considering of other alternatives. The goal of this technique is to counter the inertia of depression by generating other options. Even one additional choice challenges the cognitive distortion that there are no alternatives. Ask the patient to use the space provided in the workbook to create a list of situations in which she believes she had no options. Then, have the patient list one or more alternatives that have become clear to her now as she looks back on each situation.

Decatastrophizing When one catastrophizes, a person imagines and believes terrible outcomes will happen. Another way people catastrophize is by engaging in “what if ” thinking; imagining all the things that could go wrong. If the patient has an experience she views as potentially catastrophic, she can work to challenge whether she is overestimating the potential consequences of the situation. Questions the patient might ask include:

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“What are the terrible outcomes I am considering?”

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“Could I survive that?”

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“If it does happen, how will my life be different 3 months from now?”

Have the patient write down an event or circumstance that she believed would lead to a catastrophe or disaster. Next, ask the patient to write down what she thought would happen and then what actually happened. This exercise is intended to remind the patient that consequences in the past have not always matched her catastrophic thinking. Even though bad things happened, the world did not end.

Examining Expected Consequences In this technique, the patient is asked to think about a situation and describe her concerns and expectations related to it. Often, describing expectations can reveal misperceptions and irrational thinking. Alternatively, if the anticipated consequences are likely, the patient can realistically assess danger and develop effective coping strategies. An active examination of the style, format, and content of the patient’s expectations can yield good material for challenging irrational thinking. Have the patient use the space provided in the workbook to list any negative expectations of people or events that may frighten her or negatively influence her behavior. Then, instruct the patient to rank the chances that such an event will happen on a scale from 0 to 100% and then list one to three options that may be appropriate to that expectation. The patient may want to rank-order options in terms of effectiveness.

Listing Advantages and Disadvantages Another approach for challenging negative thoughts is to look at the pros and cons of the beliefs that maintain depression. By focusing on the

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advantages and disadvantages of a particular behavior or way of thinking, the patient can achieve a more reasonable and adaptive perspective. This technique can be used to examine the adaptiveness of acting, thinking, and feeling certain ways. Although individuals who are depressed often claim that they cannot control their feelings, viewing personal options from a broader perspective can enhance the view of choices and personal control. Have the patient use the space provided in the workbook to list situations that she finds troublesome. Then, ask the patient to evaluate the different options for resolving each situation by listing advantages and disadvantages.

Turning Adversity to Advantage As is often the case, for each thing lost, something important is gained. Sometimes what seems like a disaster can be used to advantage. Losing a job can be a disaster but may be the entry point to a better job or even a new career. A deadline may seem oppressive and unfair but may be used as a motivator. This technique asks the “depressed you” to look for potential creative or adaptive outcomes. Looking for the positives of a difficult situation can be challenging. The “depressed you” will sometimes respond with even greater negativity when the “challenger” points out positive possibilities. The “depressed you” may accuse the challenger of being unrealistic. The challenger can point out that the positive view is no less real than the negative view. Ask the patient to think of negative events that have happened to her. For each event, instruct the patient to try to think of one positive outcome or one thing that she learned from the event.

Labeling Biases and Distortions One of the first steps toward self-knowledge is identification of distortions or errors in thinking. Many individuals who are depressed may find it useful to label the cognitive biases and distortions they notice

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among their automatic thoughts. Although not essential for improvement, labeling is often helpful because it helps the patient see things from a cognitive therapy perspective, and helps the patient understand the style and format of her bias. Refer the patient back to the list of cognitive biases and distortions in Chapter 7 of the workbook. Ask the patient to practice labeling her negative thoughts using the list.

Guided Association and Discovery Having the patient invoke the challenger through simple questions like “Then what?” and “What would that mean?” can help the “depressed you” explore the significance of events and potentially uncover underlying assumptions and beliefs that the patient was not previously aware of. Using the chained or guided association technique, the “challenger” works with the “depressed you” to connect ideas, thoughts, and images. Asking questions like “What evidence do I have that that is true?” allows the “challenger” to guide the “depressed you” in identifying beliefs or schema that anchor distressing automatic thoughts. The guided association can be employed in helping the “depressed you” to be identified in more specific ways. Then the patient can begin to challenge more fundamental aspects of what underlies patterns of depression specific to her as an individual. This process is like peeling an onion, layer by layer. Instruct the patient to use guided association to challenge three negative thoughts.

Using Paradox or Exaggeration Ironically, taking an idea to its extreme can make it possible to view a situation or thought from a more realistic position. Help the patient search for a negative thought she might have that may be exaggerated or extreme. Then, have the patient restructure the thought in an even more exaggerated way (e.g., “I am unattractive; I really look like a hyena”). The patient should ask herself if the revised negative thought is realistic.

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Scaling Scaling is particularly useful for individuals who tend to see things as all or nothing, black or white. The technique of scaling—viewing things as existing on a continuum—helps people be more descriptive and therefore more objective and balanced in thought and feeling. Instruct the patient to choose events in her life where she experienced sadness, anger, and anxiety and have her rate the intensity of her emotions at the time on a scale of 1–100.

Replacement Imagery Not all automatic thoughts are verbal. Images and dreams can be valuable sources of material in therapy. If the patient has disturbing images, this is a way to generate more effective coping images to replace the depressing or anxiety-producing ones. Athletes have discovered that imagining specific successful performances can lead to increased actual performance during competition. Similarly, the content of dreams can be examined from a cognitive perspective. Cognitive therapists view dreams as the active expression of the person. The following example demonstrates replacement imagery. A 31-year-old woman reported the following dream: “I was sitting on the couch when out from the opposite wall came this huge snake. It struck at me with incredible speed, giving me no time to move away. It sank its fangs into my arm. All I could do was look at it and comment on the pain and the fact that it was biting me. I woke up feeling anxious and frightened.” The basic cognitive elements in this example are the woman’s view of herself as helpless and her perceived inability to effectively react. These cognitive positions paralleled her dysfunctional cognitions in her waking state. She was extremely effective at her job but often felt anxious when called upon to be assertive. Her therapist might help her restructure the experience by asking what she might have done differently in the dream. She could restructure the scene as she wished, now in

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her attentive, reflective state. As a challenger, how might she encourage herself to use more adaptive skills? At first, she restructured the dream tentatively, by visualizing herself trying to hold something over the snake hole in the wall. With further encouragement and some modeling from the therapist or the challenger, she restructured the scene so that she immediately severed the snake’s head. As she restructured the dream to one in which she took greater control and asserted herself, there was an immediate affect shift from anxiety to relief. In another technique, the dream is revisualized for the primary purpose of altering the negative elements. For example, the snake could become a cartoon character, or the dreamer could offer the snake a treat or have a transparent shield. In restructuring the dream or image, a positive outcome can be affected. Have the patient summarize one of her own dreams and then restructure it.

Cognitive Rehearsal Explain to the patient that by visualizing an event in the mind, one can practice particular behaviors mentally. A number of athletes use this technique to enhance performance. Through visualization and imagined practice, the patient can investigate several possibilities by running each of them through mentally like a DVD. Pilots practice on a flight simulator to gain skills in this way. Ask the patient to think of something she would like to learn how to do or do better. Work with her to create a visual scenario with phases, and have the patient imagine specific steps that might lead to the desired result.

Self-Instruction or Coaching The same process used in self-criticism can be used to learn and enhance new skills. For example, in learning impulse control, one can start with

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direct verbalization by saying self-instructions out loud. With practice, the patient can learn to say the instructions without actual verbalizations and eventually the instructions become more automatic. The patient can learn to offer direct self-instructions or, in some cases, counter instructions. In this technique, the “challenger” is not introducing anything new to the “depressed you.” Rather, the patient can utilize, change, and strengthen a technique that has been used before. Ask the patient to think of a situation in which she wishes she could curb her impulse to act until she has cooled down or thought the situation over (e.g., when her child is misbehaving, or when she is reprimanded at work). Ask the patient, “What are some things you would like to tell yourself if you could wait before reacting to the situation?”

Thought Stopping Distressing thoughts often have a snowball effect. What may start as an insignificant problem can gather weight and momentum. Once on a roll, the thoughts seem to have a force of their own and are very hard to stop. Thought stopping is best used when the thoughts first start, rather than after they are already underway (Burk, Randolph, & Probst, 1985). The “depressed you” can be taught to picture a stop sign, hear a bell, picture a wall, or say the word “stop” out loud, or clap her hands. This technique may be practiced in a session with the patient. The patient can then remind herself of her success at stopping or interfering with her own thoughts in session when she practices on her own at home. Instruct the patient to write down some of the repetitive, negative thoughts she has that she would like to stop. Have the patient list them in the space provided in the workbook and practice stopping them using any of the techniques from the previous paragraph (saying “Stop!” out loud, clapping her hands, imagining the sound of a bell, etc.)

Focusing There is a limit to how many things a person can think about at once. By occupying her mind with neutral thoughts, the patient can learn to interfere with or block upsetting thoughts.

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Ask the patient to review the negative thoughts she listed in the previous exercise and try to focus on something neutral or pleasant to interrupt the thoughts. Each time the patient becomes aware that she has drifted back to her negative thoughts, she can simply refocus on the neutral image. Caution the patient that mastering this technique takes repeated practice. She can be advised to set aside 10–15 minutes each day to practice this exercise.

Self-Compassion Problems can be more effectively managed if issues are dealt with in a neutral and pragmatic manner. You might ask the patient how she feels if someone respectfully asks her to stop talking in a theater rather than yelling or cursing at her in anger. When listening to the patient, do the words the patient uses seem to wag a finger of self-condemnation and/or self-accusation? The effect of these harsh messages, both in selftalk and from others, is often met with resistance and conflict. How we address ourselves when we are suffering can make a difference in problem-solving. The premise here is that the depressed person often is more understanding of other peoples suffering and problems and has difficulty offering the same sympathy to herself. In the first column of the exercise sheet in the workbook, have the patient write a self-punitive, mean spirited, and condemning selfstatement. Then have the patient respond to that thought in the opposite column with understanding and sympathetic statements that she might give to a friend or loved one who is suffering.

Signal or Noise? Noise is something that distracts focus from important signals. It is possible for a patient to overemphasize some aspect of the environment at the expense of noticing more important or useful signals that promote her goals and purposes. For example, if a person travels in rush hour traffic, she can become distracted by the crowded highway and become so upset about it that she arrives at her destination in an irritable state

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of mind. However, most people find ways to accept the difficulties of travel and focus on where they are going and perhaps listen to the music on the radio rather than emphasize the “noise” of the highway. Ask your patient to consider situations where she overemphasizes noise in her life when she could be more focused on other signals.

The Automatic Thought Record The Automatic Thought Record (ATR) presented in this chapter (see Figure 8.1) is one of the most widely used methods in therapy for changing thinking patterns and levels of emotional distress. Learning to use the ATR takes practice, but it is well worth the effort. Ask the patient to collect information about distressing situations between sessions and write them down. This will give an opportunity to apply the understanding of the cognitive distortions and the cognitive therapy techniques using this format for the patient to generate responses to automatic thoughts. Review with the patient the following instructions for completing the ATR.

Situation The second column of the ATR is labeled “Situation” (the first column provides space to record the date and time the situation occurred.) Here, instruct the patient to provide a neutral description of a situation or circumstance in which she found herself experiencing emotional distress. Have the patient describe what she was doing, where she was, and/or who she was with when she felt bad. This is the “S” in the BEAST and the second component of the cognitive triad (environment).

Emotions In the third column of the ATR, instruct the patient to record the feeling(s) she experienced during the situation or event in which she felt depressed. A feeling is usually a word or two (i.e., anxious, sad, afraid, angry, etc.), not a description of how, what, or why. You can help the

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patient if there is difficulty identifying exactly what is felt. In Chapter 7 of the workbook there is a list of commonly experienced feelings to aid the patient who may have difficulty identifying emotions. Often people confuse thoughts and feelings. The feeling is associated with the previous column (situation) and the next column (automatic thought). After the patient has identified the feeling(s), ask her to rate the intensity of the feeling(s) on a scale of 1–100%, where 1% represents low or no intensity and 100% represents the most intense feelings the patient has ever experienced. To help the patient understand intensity ratings, explain that anything over 50% can be seen as uncomfortable. Anything below 50% is manageable. Impress on the patient that it is normal to experience some uncomfortable feelings even if she is in a good mood. All 0% discomfort level is uncommon.

Automatic Thoughts Automatic thoughts (ATs) are the thoughts associated with the particular feelings identified. Instruct your patient to record her ATs in the fourth column of the ATR. Have the patient also rate her belief in these thoughts on a scale of 1–100%, with 1% representing no belief and 100% representing absolute belief in the thoughts. The continuum or percent of belief is important to allow the patient to experience doubt. Anything that the patient views as all-or-nothing may not make as much sense once it is put on paper. Writing down thoughts helps bring a mindful distance from the ideas that are associated with distress. This distance from the thought allows for consideration of alternatives.

Adaptive Thoughts These are responses to the automatic thoughts. The patient should also rate her belief in these adaptive thoughts on a scale of 1–100%, with 1% representing no belief and 100% representing absolute belief in the thoughts. Following are some other rules of thumb to follow when generating alternative thoughts.

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1.

Address only one automatic thought at a time. If there are several automatic thoughts associated with the feeling, the patient is advised to choose the one that seems the strongest. Other thoughts can be examined later if the distress is still very strong. Explain to the patient that trying to address several thoughts at once may increase the feeling of being overwhelmed. Also, when one thought is addressed with alternative ideas, it may make the other thoughts lose their depressive effect too.

2.

Encourage the patient to come up with at least three adaptive thought responses for each automatic thought recorded on the ATR. They are more powerful when they are specific and contain evidence (preferably from the patient’s own life and experience) to dispute or offer alternatives to the content of the automatic thought. If the thought is a realistic problem, problem-solving skill building can be a part of the contents the patient writes in this column.

3. Use descriptive rather than judgmental or value-laden language. Instruct the patient to be compassionate to herself about what she is feeling and move away from being self-punitive. Identify any language distortions, like “should,” “have to,” “must,” “always,” and “never.”

Outcome In the last column of the ATR, the patient will record what happened as a result of challenging her ATs and re-rate the intensity and believability of her feelings and thoughts. The patient can also add any new feelings or thoughts that may emerge about the situation. See Figure 8.1 for an example of a completed ATR. Blank copies of the record are provided for the patient in the workbook. Instruct the patient to complete the ATR whenever she finds herself experiencing feelings of distress. There is also a form in the workbook where the patient can record her use of the cognitive techniques introduced earlier in the chapter.

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Date and time

Situation (Describe the circumstances)

11–10–09

I am in the car and thinking about the things I forgot to do at work.

Anxious (90%)

I was told that the job ends in 30 days and I will be laid off.

Depressed (80%)

5:15 p.m.

11–11–09 3:45 p.m.

Figure 8.1

Example of Completed Automatic Thought Record

Emotions (Write your feelings and rate them on a 0–100% scale)

Fearful (95%)

Hopeless (90%)

Automatic thoughts (Write your automatic thoughts and rate your belief in them on a 0–100% scale)

Adaptive thoughts (Write an adaptive thought and rate your belief in it on a 0–100% scale)

Outcome (Describe what happened as the result of your actions)

If I don’t get the work done for my boss, he’s going to kill me! (95%)

I have a good record with my boss because I usually get the work done early. (90%)

Anxiety is reduced to 40%. Fear is at 50%. New feelings: Calm–60% Confident–55%

I won’t be able to support my family if I don’t have this job. (99%)

I knew when I started here that this was not my life’s work. (70%) We have saved money and my parents are able to help us. (70%)

Depression is reduced to 60% Hopelessness (40%)

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Mindfulness, Meditation, and the Evolution of Cognitive Therapy for Depression Throughout this program there are references to mindfulness, a concept that is Eastern in nature, related to Buddhist and Hindu practices of mind training. The most similar concepts in Western culture and psychology are awareness and being in the present. Since the 1990s there has been great interest and emphasis on research and reference to the term mindful as it relates to the treatment of depression. Methods such as transcendental meditation were empirically researched for positive effect on stress reduction beginning in the 1970s (Benson, 2000). In 2005, at the International Congress of Cognitive Therapy, the Dalai Lama participated in a dialogue with Aaron T. Beck. In an essay reflecting on his meeting with Dalai Lama, Dr. Beck looked at the compatibility of Buddhist approach to well-being and its relationship to the cognitive therapy. Areas of concurrence included the importance of acceptance, compassion, knowledge, and understanding. Both Buddhist thought and CT see the attachment of negative meanings to events as part of the problem in thinking for those in distress. Methods that are similar in both frames include a focus on the here and now and an identification of toxic beliefs and distancing from those beliefs to gain wider perspective. Mindfulness in cognitive therapy incorporates specific methods to move away from rumination about negative affect and encourage the patient to simply remain aware of her mental activity without judgment. It involves an attitudinal shift toward acceptance, rather than avoidance of difficult experience. The patient learns to view thoughts as events in the mind, independent of their content or emotional charge (Finucane & Mercer, 2006). It is beyond the purview of this program to instruct the therapist in the methodology and techniques of mindfulness-based therapy. Current research is focusing on meditation as a component of the treatment of depression. For extended discussions of these interventions that focus on meditation, body awareness, and focused awareness of the present moment, see Kabat-Zinn (2006); Ivanoski & Malhi (2007); Segal, Williams, & Teasdale (2002).

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Meditation Methods in meditation are outwardly simple. The rationale can be as straightforward as teaching another means of relaxation. If you determine that your patient may benefit from a meditation practice and decide to introduce the idea, you can do so with the confidence that there are empirical studies that suggest many benefits with continued practice. If she is receptive to the idea and wants to explore the practices further, we recommend books and CDs by Jon Kabat-Zinn, Alan Wallace, and Herbert Benson. Instructing the patient is best done collaboratively in a session. The following technique is one that is easy to demonstrate. I am going to show you an exercise to relax and get some of the noise and clutter to settle in your mind. There is a lot of support for using this type of method and if you like what we do here today, I can give you some references to explore it further. Meditation is a rest period when you are awake to recharge your batteries and improve the possibility of focusing on tasks ahead with less stress from distraction. This type of meditation is focusing your mind on one sound, which will be the word “one.” As simple as that seems, we often find our minds drifting to other thoughts and concerns and when we notice this happening, we let the word “one” back into our minds and let the other thoughts and concerns subside. This kind of distraction is common and frequent for most people who try and meditate, so please do not worry that you are doing it wrong if you find distracting thoughts going in and out of your mind. The exceptions to this are emergencies such as going to the bathroom or attending to an urgent problem that cannot be avoided for 20 minutes or so. We go into and out of a meditation gently and purposely. I suggest giving yourself a 20-minute period each time you meditate. The process of meditation is done sitting down in a comfortable chair. Try and be in an environment where interruptions are unlikely. Turn off any alarms, your cell phone, and music. It is better to meditate at least an hour after a meal or before eating. There is always noise around us and within us, but taking some measures to lessen the noise can make the meditation easier. While sitting, please begin to take full

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breaths slowly and gently and get yourself at ease in your chair. In a few moments I am going to ask you to close your eyes. I will then say out loud the word “one” and you can repeat it after me. I will then ask to say it in a softer voice. Next, I will ask you to mouth the word as I say it aloud. After that I will ask you to continue saying the word in your mind. I will let you go for a few minutes and then I will ask you to stop saying “one.” Next, I will then instruct you how to gently come out of a meditation and back into activity after a wakeful rest. That will involve taking about a minute to gently move around in your chair and ease into active awareness of things around you. After that, I will ask you to gently and slowly open your eyes, letting a little light in at a time. The effort will be to not be abrupt or jarring, but to smoothly come back into wakeful activity. When you try this on your own, you can monitor time by opening your eye briefly and checking a watch or clock.

Homework

✎ ✎ ✎ ✎

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Have patient review Chapter 8 of the workbook and complete the exercises. Have patient choose some of the cognitive techniques listed in this chapter and record use on the Cognitive Techniques Practice Chart in the workbook. Instruct patient to begin using the ATR to monitor and challenge negative, automatic thoughts. Encourage patient to practice meditation on a daily basis.

Chapter 9

Relapse Prevention

(Corresponds to chapter 9 of the workbook)

Therapist Note

The number of sessions required to complete this module is determined by the therapist according to the specific needs of the individual patient. ■ ■

Materials Needed ■

Patient’s previously completed Activity Schedules

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Patient’s previously completed Automatic Thought Records (ATRs)

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Patient’s previously completed Tracking of Mood (TOM) Forms

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Define relapse

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Discuss common factors for relapse

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Collaboratively develop a relapse prevention plan

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Develop a crisis intervention plan if needed

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Review progress and encourage continued assessment

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Discuss other ways to decrease the potential for relapse

Outline

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Does Depression Return? Research shows that depression once experienced is likely to recur (NIMH/NIH Consensus Development Conference statement, 1985; Keller, Lavori, Lewis, & Klerman, 1983; Paykel et al., 1995). Further, it was determined that with each depressive episode the chance of recurrence is increased even more (Soloman et al., 2000). No single course of treatment guarantees a cure for depression for all time. If the patient has been actively engaged in the TTB program by doing the recommended homework and practicing the techniques included in the program, his depression is very likely to be significantly reduced if not relieved altogether. It doesn’t end here, as the research informs us. It can be reasonably hypothesized that if the patient returns to his maladaptive ways, there may be an even stronger possibility that he may find himself sinking into yet another episode of depression. This can be compared to the individual who goes on a rigorous diet and loses a substantial amount of weight, only to return to his previous unhealthy eating habits and lifestyle, and regain the weight. Some may return to drinking alcohol to excess, while others to abusive relationships or toxic situations or otherwise place themselves at high risk for relapse.

What is Relapse? In general, the word “relapse” means returning to a disease state after achieving a period of health or recovery. As research indicates, risk of relapse in varying degrees is a reality for all individuals who have achieved recovery from depression. One reason for relapse may be that the individual continues to think and or behave like he did prior to the remission of the depressive symptoms. This may be one of the main reasons that medication alone often fails to provide lasting relief from depression; that is, not paired with an ongoing coping and skills focus. One study specifically focusing on relapse involved 99 individuals in remission from a major depressive episode who were experiencing “risky thought patterns.” These individuals had received different treatments to achieve remission. Forty of them recovered after a course of treatment with antidepressants only and 59 had received CBT. All were evaluated

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regarding their dysfunctional attitudes and in the experimental situation listened to sad music at half speed, while at the same time being asked to remember a time in their lives when they felt sad. Results indicated that that those whose thinking became most dysfunctional during this exercise were also the most likely to relapse within the next 18 months. In other words, their “cognitive reactivity” to the stimulus situation was a very strong predictor of depression relapse; even greater than the strongest previously known predictor for relapse; number of prior relapses (Segal, Kennedy, Gemar, Pederson, & Buis, 2006). For those who were treated with medication only, even mild sadness was more likely to trigger dysfunctional thinking than for those who were treated with CBT (Segal et al., 2006). An important implication from this study of relapse prevention is that thoughts and behaviors can play a very important part not only in the development of depressive symptoms but the interruption of their persistence, promulgation, and return, as well. It would then follow that a relapse prevention plan could likely decrease the risk of relapse.

Common Factors for Relapse Not infrequently patients who believe they have conquered depression do return to their old habits and ways of thinking. There are several factors that can contribute to this. Some may lose sight of the specific elements that contributed to the evolution of their episode. Some may not fully comprehend the part that they themselves played in bringing themselves out of their depression, so fail to recognize how they might actively plan to prevent its return. Others may erroneously believe that they are, and will be, impervious to those same vulnerabilities and situational factors in the future. In the earlier sections of this guide, we outlined those situational, behavioral, vulnerability and health-related factors that are often closely related to depression. In assessment, it was important to include data regarding the circumstances under which the depressive episode occurred along with the behaviors, thoughts, images and feeling that accompanied them, and physical factors and other health-related factors involved (DiTomasso & Gilman, 2005).

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Specific factors for relapse for depression include: Vulnerability Factors ■ ■ ■ ■

■

■ ■

One or more (multiple) prior episodes Strong family history of depression Prior suicide attempt Physical conditions and illness, (e.g., pain, diabetes, myocardial infarction) Use of medication such as sedatives, opiates for pain, prednisone, hypertensive agents Sleep disorders Alcohol and/or drug abuse

Situational Factors ■ ■ ■ ■ ■ ■

Lack of social support, connectedness, and satisfying relationships Life losses Abusive relationships Work stress and job dissatisfaction Major life transitions such as job changes, moves, and retirement Financial distress

A well thought-out, relapse prevention plan should include special attention to these factors as they specifically pertain to the patient’s life. Use the following case example to illustrate this concept.

Case Example Katie left the front door of her apartment and headed for her car. She was on her way to see her mother who was expecting her to celebrate her brother’s birthday. The gift for him was in one bag and a casserole was in the other. The street was a pretty tree lined avenue with a couple of children riding bikes down the sidewalk in front of her and an elderly couple walking hand in hand on the other side of the street. She really liked her quiet neighborhood. It was a lot like the street she grew up on, where she always felt safe and enjoyed coming home. She placed two bags on the backseat, got in the car, humming merrily under her breath. As she started the car Katie looked across the street

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and noticed the elderly couple again. Just then she had a quick memory of her grandmother. Her first thought was, “I really miss my nana.” Katie began to feel very sad. She thought of her tiny face and her wrinkled hands. She remembered how they used to walk together down the street in front of her grandmother’s house. It had been 10 years since her grandmother had died. Oh, how she wished she could spend one more day with her grandma who had died so soon. She began to sob, placing her head in her hands and soon, she was so overcome with emotion that she felt unable to pull herself together. Katie got out of the car, ran back into her apartment, and impulsively called her mother to say she just couldn’t make it that day; that she wasn’t feeling well. In this example, Katie fell prey to her own negative thinking. There was nothing different between leaving her front door and starting her car, except her thoughts and feelings that had been triggered by seeing the elderly couple that reminded her of her grandmother. Katie had not placed any protection between the “trigger” and the automatic thoughts and feelings that were significant part of her earlier onset of depression. Before long she was experiencing profound sadness and negative feelings to the point that she did not go to an event that she otherwise would have enjoyed. Consider the alternative, and imagine how things would have been different if Katie had used a specific relapse prevention plan, applicable for just such times. As she started the car Katie looked across the street and noticed the elderly couple again. Just then she had a quick memory of her grandmother. Her first thought was, “I really miss my nana.” Katie reminded herself that sadness was natural and of course she missed her grandma. She also reminded herself that she was particularly sensitive or “vulnerable” to such feelings and related automatic thoughts. She reminded herself that this was a signal to use her self-interventions from her relapse prevention plan. She would stop and say to herself, “Having these feelings doesn’t mean I am depressed, it is an expected response to being reminded of my grandmother.” I can acknowledge them but don’t have to go all the way into them or be driven by them. I have choices of what to do in response to this feeling.” She asked herself “What do I really want to do?” Then responded, “Remember, I

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really wanted to my brother’s party!” Katie then firmly replaced the thoughts, feelings, and images of her grandmother with “here and now” thoughts, plans, and images of her very-much-alive mother and brother whom she also loved. She reminded herself that although her grandmother had been important to her, her mother and brother were equally important in her present life and predicted from past experience that if she went on to the party she would likely feel better about herself. With these thoughts in mind, Katie was able to motivate herself to go to the party, despite her strong feelings. The difference between the first story and the second (in addition to the outcome) is that in the second example Katie had a relapse prevention plan in place that addressed just such situations. When the first thoughts and feelings came to mind in response to this “trigger,” she acknowledged them and immediately chose to interrupt the distressing thought-feeling-behavior cycle. Even though she was temporarily distracted by painful feelings of sadness, and related automatic thoughts, she was able to intervene and shift her focus to live more in the present, rather than be held hostage by those memories. Her skill in becoming aware of each step and intervening effectively took much practice. In the second scenario, Katie had become her own therapist and by doing so interrupted a feeling-thinking-behavior cycle that eventually could have extended to an enduring low mood and subsequent depression.

Developing a Relapse Prevention Plan Patients who develop mastery of the skills taught in the TTB program will have a broad repertoire of coping techniques and interventions to use against low mood, associated thoughts and behaviors that may signal the beginning of depression. Explain the necessity of a relapse prevention plan and engage the patient in its formulation. You can explain that with planning in how to use his skills in response to future disappointments, losses, situational stress, and his own unique “triggers,” he is more likely to interrupt repetitive thought patterns and enduring low moods that could eventually result in another episode of depression. Or in the event he does become depressed in the future, his efforts can significantly decrease its impact.

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The first step in making such a plan is to review with the patient his list of his own vulnerability and situational factors, previously identified in the assessment and throughout the treatment. This includes identifying his characteristic thinking patterns and behaviors that contributed to his depressive episode. Similar to the TTB program, an effective relapse prevention plan is tailored to individual needs of patients. Both the therapist and patient need to keep these unique factors in mind. In addition to past vulnerabilities and situations, ask the patient to identify possible future situational changes and challenges. Next, ask the patient what he has learned in psychotherapy that has been most helpful in alleviating his depression. Areas of focus are: restructuring thoughts and underlying beliefs, managing feelings and relationships, and limiting the effects of vulnerabilities and situational factors. This can be accomplished by reviewing previously completed worksheets including the Automatic Thought Record and TOM Form, and other homework assignments, ideally organized into a folder or notebook. Be specific in your questions and challenge the patient to be specific also. This kind of review allows the patient to determine specific techniques that have been helpful, provides an opportunity to reinforce the patient’s learning, shows the incremental nature of his progress, and overall provides evidence necessary for the patient to claim credit for his own accomplishments. In addition to being helpful in further identifying specific vulnerabilities and other factors involved in the patient’s depression, it can elucidate those “triggers” for automatic depressive thinking and feeling. Lastly it can assist in determining your patient’s readiness for termination. As shown in the case example, an effective relapse prevention plan includes those unique “triggers” for the patient and specific suggestions for managing them, or in some cases appropriately avoiding them altogether. Triggers are those specific situations, people, times, and even thoughts or behaviors that act as powerful stimuli for thinking and feeling pattern associated with depression. Have the patient list them and develop a list of options for each one. Relapse prevention is really an approach to living well and represents a philosophy of life, but the plan itself is much more specific. Ideally it is

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written in an organized fashion with the relevant information in simple, specific terms. It should be readily accessible and easy for the patient to refer to. It can take a variety of forms; a series of note cards categorized by topic, a notebook, or folder with information organized in sections. Following is a sample Relapse Prevention Plan (see Figure 9.1). Some of the items have been completed to show you how the patient might be guided in completing it for himself.

Specific vulnerabilities to depression and things that can be done to lessen their potential impact: 1.

Sleep deprivation ■

Record those late night TV shows I like and watch them the next day.

■

Keep my sleep tips sheet handy so I can refer to it every night.

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If I’m up worrying for more than 10 minutes at bedtime, I will leave my bedroom and sit in the living room until I am ready to return to bed.

Situations that contributed to episode(s) of depression and three things (i.e., coping, problem solving, or decision-making strategies or actions) that alleviated the situation or impact: 1.

I isolate myself and became lonely ■

Remind myself that feeling lonely may be an early warning sign, but that it does not mean I am destined to become depressed.

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Remind myself that there are things I can do to prevent an onset of depression.

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Call at least three of my friends and schedule a get-together with them once a week.

Anticipated situations that would present challenges and could contribute to future episode(s) of depression and three things I can do to lessen their effects (i.e., coping, problem solving, or decision-making strategies or actions): 1.

Visiting my mother who is very critical of me ■

Limit my visit to 3 days.

Figure 9.1

Sample Relapse Prevention Plan

160

■

Review my Automatic Thought Records and other written therapy work relating to coping with my mother’s criticisms prior to the visit.

■

Explain to her that I love her and understand that she might be trying in her own way to get me to change, but I will not stay the entire visit if she continues to berate me.

Most distressing emotions and three ways of dealing with them: 1.

Anger ■

Acknowledge that I am angry rather than burying it inside.

■

Remind myself that expression of anger is a choice. I do not have to express it immediately when I experience it.

■

Delay expressing anger and let it subside, and then decide how I can best express it. I can make better decisions when I let things incubate.

Most frequent automatic dysfunctional thoughts and the three most effective, adaptive responses to each one: 1.

I am doomed to be depressed all of my life ■

I was depressed before and brought myself out of it.

■

I can recognize the signs earlier and have a better chance of preventing an episode.

■

I have learned specific skills that I can use in the future if I do get depressed.

Specific triggers for automatic thoughts and distressing feelings: 1.

When I see a movie in which one of the characters is a critical mother ■

Remind myself that this is a trigger but not my life.

■

Remind myself that I have a choice of allowing myself to go into the pattern of self criticisms or not.

■

Review and use the ATRs that I have completed re my mother’s criticisms

Figure 9.1 continued

161

Core dysfunctional (maladaptive) beliefs with three automatic thoughts that reflect them and effective, adaptive responses to each one: 1.

I am inadequate ■

My mother tells me so, so it must be true.

■

Review and use my ATRs re my mother’s criticisms.

■

Remind myself that I have a college degree and a good job, both of which show that I am more than adequate.

Criteria for knowing when to return to psychotherapy: 1.

Mood score of

for

2.

BDI-II score of

for two consecutive times

3.

Suicidal thoughts

4.

If I lose my job or someone close to me passes away

5.

If I am diagnosed with a serious illness

days

Who to call for support, help, or companionship when lonely: 1.

Phone Number:

2.

Phone Number:

3.

Phone Number:

Figure 9.1 continued

Crisis Coping Plan For patients who have had suicidal thoughts or have attempted suicide in the past, develop a separate, crisis coping plan to specifically deal with these or other self-harming thoughts and urges. Such a plan can be extremely effective in preventing suicide attempts by those diagnosed with recurrent depression (Yates, 1992). It also might be appropriate to have a separate crisis plan for specific anticipated crises other than suicidal thoughts. For example, the patient could develop a plan in case of suicidal thoughts and another in case of urges to impulsively act in other destructive ways (e.g., quit a job or take more than the

162

recommended amount of prescribed medication to get to sleep). As with the relapse prevention plan, this is formulated directly from what has been successful in the treatment. Figure 9.2 shows a sample Crisis Coping Plan for a patient who may have the urge to take extra medication in order to get to sleep.

Progress and Continued Assessment The process of developing the relapse prevention plan and crisis coping plan provide another opportunity to assist the patient in claiming credit for the progress he has made throughout the course of therapy. You can encourage this in a number of ways. The language you use in your inquiry can reflect this encouragement. Examples of these questions are, “How did you get yourself to think differently? How did you manage to resist the impulse to give-in to those feelings, and try something new? What does your success in dealing with your depression tell you about yourself and possibilities for the future?” Anticipate that inevitably there will be some future mistakes and setbacks. Ask the patient what he could remind himself of at those times and put it in the form of a list or a letter to himself that he can read when he feels particularly discouraged in the future. In addition to enhancing self-understanding and skill reinforcement, this exercise could encourage self-compassion as well. The effective implementation of a relapse prevention plan involves regular review and continuing assessment of mood. The patient can keep available a number of blank BDI-IIs and Activity Schedules for this purpose. Suggest the patient use time samplings in which the patient assesses his mood at the same time, each day during times of vulnerability or stress, several times a week or once a week during non-stressful periods. Suggest the patient frequently monitor his environmental or situational stressors and assess any ongoing vulnerability factors. The TOM Form is useful for tracking the results of these assessments over time.

163

In the event I have an urge to take extra sleeping medicine to get to sleep, I will remind myself of these things: 1.

It is dangerous for me to be that sedated.

2.

It is not healthy to build up a tolerance to sleeping medicine.

3.

The last time I took extra medication I was so groggy that I didn’t go to work the next day. I don’t want to lose my job.

4.

It won’t be a catastrophe if it takes a while for me to get to sleep.

5.

This is a signal for me to use my sleep aid tips and get back into my good sleep routine. This has helped me before.

6.

This is a danger signal. Tomorrow I will try to figure out what is going on with me that I would consider taking too much medicine.

Things to do: 1.

Use my relaxation and calming techniques.

2.

Get out of bed and do something useful if I can’t sleep after an hour.

3.

Commit to myself that I will get some good exercise tomorrow.

4.

Reevaluate my sleep plan tomorrow if tonight does not go well.

Who to call for support or help or in an emergency: 1.

Phone Number:

2.

Phone Number:

3.

Phone Number:

4.

Therapist

Phone Number:

5.

Hospital

Phone Number:

Figure 9.2

Sample Crisis Coping Plan

164

Decreasing the Potential for Relapse In addition to a good relapse prevention plan, there are several other important things that the patient should keep in mind. First, he must use the plan! Encourage him to review it regularly for relevance and reinforcement of use. Next, you and the patient should agree on those indicators that signal the need for him to return to formal psychotherapy. These might include a significant drop in mood, low mood over two or three continuous samplings, a persistent low mood over a week or two, an increase in several symptoms at once, or suicidal thoughts. The important thing here is to help the patient know when to ask for help, either from you or from others.

Mindfulness There has been important research in the area of relapse prevention involving mindfulness practice. As discussed in previous chapters, mindfulness is the practice of observing one’s experience in a way that is fully aware and non-judgmental. The practice of meditation involves simply noticing or observing both one’s mind and body, without judgment and without trying to change what is observed. The result is often paradoxical. Through the practice people can come to view their specific feelings and emotional states, as they ebb and flow, without the distressing effects. The use of CBT techniques; homework writing tasks, daily practice of restructuring thought patterns, and behavioral change rehearsal all assist patients in gaining some distance from the distressing effects of their feelings. Through these practices, people can become aware of their thoughts and feelings in a non-judgmental way. There has been growing interest and some very promising research over the past decade focusing on mindfulness practice and CBT. (Baer, 2003) Although there has been little research supporting the use of mindfulness practice as a specific treatment modality with depression, (Eisendrath, 2006) there has been stronger empirical support for its use with anxiety disorders and panic and impulse control (Kabat-Zinn et al., 1992; Miller, Fletcher, & Kabat-Zinn, 1995; Roemer & Orsillo, 2007).

165

Schwartz used mindfulness-based cognitive therapy with OCD patients in which they learned to think about their thoughts differently. A majority of them improved significantly. This could have some promising implications in intervening in the ruminative aspect of depression (Schwartz & Begley, 2002). Particularly relevant to relapse prevention, Segal, Williams, and Teasdale (2001) developed a model of “maintenance CBT” including mindfulness-based stress reduction (MBSR), a meditation developed by Jon Kabat-Zinn (1990). Several independent studies of people with recurrent depression receiving MBSR after treatment as usual showed significant reductions in relapse rates, even when compared to those receiving pharmacotherapy following treatment. (Ma & Teasdale, 2004; Segal, Williams, & Teasdale, 2002; Segal et al., 2006; Teasdale et al, 2000; Teasdale et al., 2002)—Others have replicated the studies focusing on relapse using other types of mindfulness practice. (e.g., Kuyken, 2007). On the basis of this growing body of research we believe that daily mindfulness practice could be a very important element of an effective relapse prevention plan. For further information about the practices, and specific instructions in the practice, we encourage you to contact the researchers and authors directly and read their wealth of published materials.

Final Tips There are some general tips the patient might find useful as he incorporates what he has learned from the TTB program into his life.

166

■

Use the relapse prevention plan as a way of life.

■

Maintain a healthy lifestyle of eating, sleeping, and doing moderate, regular exercise in a calm way.

■

Find ways to soothe yourself in times of stress such as doing yoga, meditating, getting massages, listening to music, or attending religious services.

■

Avoid excessive use of alcohol and drug abuse.

■

Set realistic, manageable daily goals.

■

Maintain a balance in thinking and emotions.

■

Engage in respectful, satisfying relationships.

■

Be self-protective. Avoid toxic situations and people, and abusive relationships.

■

Respect vulnerabilities and remember being hungry, angry, lonely, and tired increases vulnerability.

■

Manage impulsive urges against undesired consequences.

■

Encourage yourself to be self-compassionate.

■

Remember, mistakes and setbacks are inevitable to the human experience. Rather than being self-punitive, ask, “What can I learn from this?”

Homework

✎

✎ ✎

Ask the patient to review his previously completed Activity Schedules, Automatic Thought Records, Vulnerability Factor Worksheet, Feelings Logs, and TOM Forms and write down those things that were most helpful to him in treatment. Have the patient list specific things he tried that were not particularly helpful and what he learned. Refer the patient to the workbook and appendix for extra copies of blank Activity Schedules, Automatic Thought Records, and Tracking of Mood Forms to be used in his ongoing review of the relapse prevention plan.

✎

Have the patient complete the Relapse Prevention Plan.

✎

Have the patient complete the Crisis Coping Plan, if needed.

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Chapter 10 Ending Treatment

(Corresponds to chapter 10 of the workbook)

Therapist Note

The number of sessions required to complete this module is determined by the therapist according to the specific needs of the individual patient. ■ ■

Materials Needed ■

Patient’s completed TOM Forms

■

Patient’s completed Automatic Thought Records (ATRs)

■

Review the elements of effective, successful termination

■

Assess the patient’s readiness for termination

■

Set the schedule for termination

■

Address possible interference to successful termination

■

Account for reality factors that interrupt therapy

Outline

Termination/Ending Therapy Ideally, ending formal psychotherapy is a collaborative decision following the agreed-upon course of treatment based on amelioration or alleviation of symptoms, satisfactory progress toward stated goals,

169

and well-rehearsed use of learned self-therapeutic techniques, including activity scheduling, relaxation, and cognitive restructuring among others. The patient’s subjective experience of a general sense of satisfaction in the therapeutic experience, a sense of self-acceptance, and realistic expectations for the future all hopefully follow a successful course of psychotherapy. As discussed in the Chapter 3 on socialization, termination is an integral process throughout the therapeutic process. During the course of successful therapy, the patient’s expectations that her suffering will be magically removed is gradually replaced with more reasonable therapeutic gains, life goals, and the ability to experience pleasure and meaning in everyday life experience.

Assessing Readiness for Termination Ideally, the impetus for termination will come from the patient. Often patients will spontaneously acknowledge their progress and directly say they are ready to stop therapy. The TOM Form, introduced in Chapter 2, is useful in assessing ongoing symptom alleviation and progress toward predetermined goals throughout the course of treatment. During the formulation of a relapse prevention plan and in the final sessions of therapy, the TOM Form can be reviewed as useful in determining your patient’s readiness for termination. If your patient is more visually oriented the scores can be plotted on a graph. Subjective reports of satisfaction with the progress of therapy, pleasure, and overall satisfaction with life can also be useful to assess readiness for beginning the termination process. It is only natural that during the termination phase some patients may experience anxiety about ending treatment and leaving the comfort and structure of the therapeutic situation, and of course, their meetings with the therapist. Some may seek reassurance about what the future holds with respect to the future challenges of life. Of course, offering false reassurance is inconsistent with CBT and the TTB models and is contraindicated. These feelings and associated thoughts can be examined and explored in much the same way that other thoughts and feelings have been explored throughout the course of psychotherapy. You can realistically assure the patient that she has a basis for confidence in the

170

cognitive methods taught in the program as she continues to use them independently, regardless of the uncertainty, events, and challenges life inevitably will present.

Termination Schedule Tasks in the termination phase for patients include self-reflection, review of progress, and preparation for the future without the support and structure of weekly sessions. Although the session range for termination is suggested as 1–4 sessions, it often overlaps with relapse prevention planning so the actual number of sessions varies depending upon the patient’s readiness and unique responses. In some cases, it may be a good idea to gradually decrease the frequency of therapy from weekly sessions to bimonthly sessions, then to monthly sessions. By having increasingly longer periods of time between sessions, the patient has the opportunity to practice her newly learned skills independently. It is recommended that final termination sessions include an opportunity for both you and the patient to say goodbye. In most cases it is appropriate to assure the patient that your door is always open to her, should she need to return for more psychotherapy in the near or distant future. In fact, the establishment of periodic follow-up sessions is indicated for some patients. These sessions can take place regularly (e.g., every 3 months), or on an as-needed basis. Such an offer need not carry with it the pessimistic expectation that the patient will need follow-up sessions, rather it expresses the acknowledgement that life often presents unanticipated challenges and that if the need arises and if circumstances permit, you will be available.

Possible Interference to Successful Termination Interrupted Therapy There are several types of termination that are less-than ideal. The term “premature termination” has been used historically but is problematic in that it often implies only a therapist’s perspective and a judgmental one at that. It implies that the patient should have continued treatment.

171

The term “interrupted therapies” may be more accurately descriptive. Consistent with the view inherent in the CBT model and the TTB program, it is important to explore what is transpiring between the therapist and patient when the patient does not believe she is benefiting from treatment or when the treatment is threatened. Perhaps there are unidentified reasons for less-than desired progress toward goals. Perhaps the patient does not think therapy is worthwhile. Perhaps she does not experience the desired therapeutic alliance. All of her perceptions, thoughts, and feelings can be explored and understood with respect to the myriad of possible underlying reasons. Individuals who have chosen not to complete homework assignments, or miss appointments, and otherwise don’t optimally engage in the therapeutic process are not likely to gain the benefit that they had hoped for. Rather than assuming that the patient is only resistant or not sufficiently motivated for treatment, it might be a case that other impediments to change have gone unidentified (Freeman & Freeman, 2005b). The four most common impediments to patient change are pathological factors, environmental factors, practitioner/therapist factors, and patient factors. For example, lack of therapist or a patient’s skill base could limit change. Environmental issues are reality factors such as lack of resources to attend therapy regularly, financial problems, and unsupportive or sabotaging relatives. An example of patient pathology is underlying paranoia that prevents trust from developing a productive therapeutic relationship (Freeman & Freeman, 2005b). Attempts to prematurely end therapy may reflect a lack of therapist skill in dealing with challenging, Axis II behaviors such as persistent dichotomous thinking affecting perception and feeling experience, continued unrealistic expectation of a “cure” or one all-encompassing “answer,” or crises of confidence and fear of failure as a therapist. It may also reflect a failed therapeutic alliance or a patient-therapist mismatch. An exploration into the patient’s reasons to stop psychotherapy can begin with an examination of possible impediments to change that have not been taken into consideration previously. It is recommended that you seek consultation or ongoing supervision if the reasons center on failed therapeutic alliance of lack of therapist skill. Sometimes patients may seek second opinions from other therapists with or without discussing it with you. Should this occur, it is important

172

to explore and discuss the patient’s rationale for wanting a second opinion. It may reflect a very positive outcome, that is the patient wanting to ascertain whether termination is appropriate. Such situations require exploration, understanding, and sensitive therapeutic skill. It is also important for you to effectively manage your own feeling in response to the patient’s decision. This may represent the patient’s way of communicating that she wants to terminate with you or may alert you to unacknowledged reasons for dissatisfaction in the therapy. It is usually contraindicated to continue treating someone if she has another therapist, and termination is therefore necessary. However, if specific roles are clearly defined and expectations explicit, sometimes a course of CBT within the context of another ongoing relationship, such as with a psychiatrist who prescribes medications, is clinically appropriate. Similar to other types of terminations it is important to invite and be open to a full exploration of the reasons involved. Sometimes the patient may want to stop therapy and you believe that she may be able to benefit from continued treatment. In such a situation, it is important to have an open discussion, during which you attempt to understand the patient’s unique experience of your work together. The patient may have things to say to you that may be difficult to hear, such as you and the patient aren’t a “good fit,” or that you have been less than empathic, unhelpful, or otherwise have missed the therapeutic mark by misunderstanding. It is important in these instances to listen without defensiveness to what the patient has to say. Sometimes just the process of such an encounter can resolve the therapeutic impasse and the treatment can continue in an enriched and more successful way. A thorough exploration of the patient’s reasons for wanting to stop therapy, regardless of the reasons, may result in reconsidering the goals of therapy, changing the focus of therapy, and reformulating the treatment plan, thus resulting in a more productive, enriched therapeutic process. Ultimately, of course it is the patient’s choice and decision to continue with or leave psychotherapy. However, you can appropriately caution against what you consider an unwise choice. Following a thorough exploration you may invite the patient to return to therapy when she may be more ready or able to engage in treatment. You may recommend exploring other options, including a referral to another therapist. Even in this situation you can provide your recommendations and/or referral

173

along with an expression of confidence that the presenting problems are amenable to understanding and change. You may determine that you need to respectfully confront the patient in ways you observe that she may not be making the best use of treatment. Another possibility is through the exploration you and your patient may come to a mutual decision that she would be better served by working with another therapist. In the latter case, it is important that referrals be offered and the patient leaves with your understanding and respect.

Patient Dependency A possible interference to successful termination may be a growing dependency on you as therapist on the part of your patient. This is sometimes a surprising development when initially you might have thought you were dealing with primarily Axis I pathology. Smaller enactments of this dependency will be evident in the sessions along the way in approval-seeking, expressions of helplessness, frequent telephone calls for reassurance between sessions, and attempts to coerce you into extraordinary expressions of rescuing or heroic behaviors. Although a natural reaction to such clingy-dependent behavior is to become overly gratifying or withholding, either extreme position is counterproductive. Gratifying such demands encourages the patient’s self perceptions and reinforces the behavior, and abrupt or harsh confrontation often results in perceived empathic failure and feelings of anxiety related to perceived rejection or abandonment, resulting in an affect storm. These demands and behaviors need to be addressed with special attention to maintaining your boundaries and the relational meanings of the patient’s behavior. Therapeutic limits need to be enforced without judgment or anger. It is important to seek consultation in the situations that Davis has identified as a type of “complex termination” (Davis, 2008; Freeman, Felgoise, & Davis, 2008). With these kinds of patients it is even more important to discuss a termination plan early in therapy. A gradual decrease in frequency of sessions may be especially important also. Other possibilities may include referral to a psychotherapy group or community support group concurrently with individual therapy in order to dilute or spread out the intense transference.

174

Suicidal Ideation A potentially dangerous possibility with patients who prematurely and/or abruptly terminate psychotherapy out of pessimistic expectations or hopelessness is the possibility of underlying suicidal intent and risk of suicide. When you determine that this possibility exists, address it directly with the patient. If you hear “veiled” implicit or explicit suicidal threats or have such concerns, you need to act in an ethical and active manner. You may need to notify a family member, strongly recommend inpatient treatment or, in the highest risk situations, file a legal document initiating involuntary evaluation in an emergency room, crisis stabilization unit, or inpatient setting. Your decision to take such heroic action needs to be consistent with your state laws as well as ethical and sound clinical practice. Initial discussions during the beginning phase of treatment regarding the framework and boundaries of the treatment situation, the patient’s consent for treatment, and aspects of patient– therapist confidentiality should allow for this sort of protective action on your part. The fact that you have addressed this possibility in the Treatment Consent Form (see Chapter 3) will provide you some additional confidence and peace of mind in carrying out this crisis intervention.

Reality Factors That Interrupt Therapy There are situations in which external reality factors and circumstances interfere with treatment and premature termination is necessary. These reality factors could involve the patient or the therapist. In most of these situations, review of progress and relapse prevention can be structured in fewer sessions and you can effectively manage termination and/or facilitate transition by offering referrals.

Patient Factors For patients, reality situations that interrupt or necessitate the termination of therapy often include job transfers, residential moves, family circumstances, financial realities, and so forth. These factors are identified as environmental issues (Freeman & Freeman, 2005b). In some

175

cases and in special circumstances, the tasks of termination can be accomplished in telephone sessions.

Therapist Factors Planned terminations on the therapist’s part may be due to residential moves, office relocation, or personal or family circumstances. These may result from unanticipated family circumstances, illness, retirement, or death. Some of these terminations often can be conducted as usual. However, unanticipated or abrupt terminations involving the therapist require special planning and care. For example, you will need to thoughtfully decide what personal information you will disclose (Gerson, 1996). Also it is wise to prepare for sudden terminations by having a specific plan in place consistent with the ethics code of your professional organization. The plan should designate a colleague who has agreed to assume responsibility for contacting and talking to your patients, referring them to appropriate therapists for continuing care, and generally assisting them in the transition. Ideally, your designee is a colleague who shares your philosophy and method of treatment so that optimum continuity of care can be assured under stressful and possibly traumatic circumstances. The designee will also manage your clinical records (American Psychological Association (APA), 2002, 10.9). Specific provisions and procedures for how your plan is to be accomplished should be clearly stated and the designee should maintain a copy. When termination is initiated by the therapist, for whatever reason(s), it is necessary to carefully consider ethical and clinical issues. If you determine that your patient is not benefiting from therapy, has reached maximum benefit without full optimal change, or would be harmed by continued service, it is unethical to continue (APA, 2002, 10.10a). Such a decision needs careful attention regarding the reasons and every attempt to fully explore them with your patient to the extent that you deem appropriate. In some cases, it may be appropriate to suggest that the patient consider temporarily suspending therapy and “live with” the progress she has made up to that point. The patient can return at a later time when she is more able or ready to more fully engage in therapy. 176

Other possible reasons for therapist-initiated termination include conflict of interest or potential conflict of interest and therapy contract breaches. When it becomes clear that the patient no longer needs therapy or may be harmed by continued service, termination is indicated. If the therapist is unable to provide the treatment or level of care that is clinically indicated, termination and referral may be needed. Similarly, when it becomes evident that a dual relationship is present or if the therapist’s interests could be construed to interfere with those of the patient’s, termination and referral may be indicated. Therapists may ethically terminate therapy for non-payment of previously agreed-upon fees, but this needs to be clearly specified in the treatment agreement and discussed as the situation arises. In special situations, you may consider termination and referral when a patient repeatedly fails to respect the treatment-frame limits you have established. In extreme situations of course you may ethically terminate treatment when you are threatened or endangered (APA, 2002, p. 10b). In these situations it is important to seek consultation, specifically document the progression of events, and offer appropriate referrals.

Abandonment

One of the most important potentially problematic issues in therapistinitiated terminations is that of perceived abandonment. When you must terminate therapy for reasons of your own, patients need to be informed and opportunity provided for discussion. This does not imply that you must fully disclose of all the personal reasons involved, but sometimes it is appropriate to provide personal information when it is obvious or common knowledge. For example, if a family member has become ill or died or if you have a serious illness. In these instances, it is a good idea to seek consultations. Terminations need to be carefully planned and conducted with attention to ethical considerations to assure that patients are not left with needed psychotherapeutic care. Technically, abandonment refers to deserting or leaving something or someone and implies neglecting a responsibility. There are a number of legal definitions usually involving harm. As a legal term it involves evidence of potential for direct harm when necessary treatment is not provided (citation). In psychotherapy, abandonment is

177

much more ambiguous. When termination is not managed ethically and competently, abandonment may be determined. However, even abrupt terminations need not constitute abandonment. Some patients may interpret perceived empathic failures or any therapist-initiated terminations as abandonment, based on their schemas, underlying beliefs, and related perceptual and thought distortions. It is not a good idea to actually terminate in the midst of a crisis, however, even this cannot be avoided in every case. Setting goals and termination criteria, discussing termination throughout the course of therapy, and following the termination plan minimize the possibility of perceived abandonment.

A Final Note on Termination In addition to respectfully exploring and managing the termination experience of your patients, it is also important to reflect on your own thoughts and feelings. Occasionally you may find that you have your own difficulties in terminating treatment. These may include resistance to letting go, especially if you enjoy working with the patient, or if your work together has been interesting, stimulating, fun, or in other ways satisfying. When you consider that as therapists our goal is to “work yourself out a job” and allow the patient to leave with your best wishes, this disengagement may be easier and more meaningful. As a therapist you can take satisfaction in the therapeutic work you and your patient have accomplished together. It is a time in which you can reinforce the progress that your patient has made as well as the skills she has learned, assist her in claiming credit for the progress she has made, and say goodbye. In your own goodbye you may want to offer realistic feedback to your patient for a job well done, as well as encouragement and expression of confidence in her ability to continue to practice her newly learned skills independently. With well-based conviction, you join your patient in the expectation that continued use of newly developed skills can result in a more meaningful, pleasurable, and satisfying life.

178

Appendix of Forms

179

Tracking of Mood (TOM) Form

Assessment, Ratings BDI-II score Pleasure (1–10) Amount of sleep (hours) Activity level (1–10) Exercise (minutes) Situational stress (1–10) Vulnerability factors (1–10) Alcohol or drug use (oz.) My involvement in the TTB program (1-10) Other Satisfaction with progress (1–10)

180

Date 1

Date 2

Date 3

Date 4

Date 5

Date 6

Date 7

Medical/Physical Information Sheet Current Physical Symptoms: Yes

No

Yes

Tired

Recent weight gain or loss

Excessive sweating

Increase in appetite

Excessive thirst

Decrease in appetite

Swollen glands

Food intolerance

Increased/decreased body hair

Nausea/vomiting

Nipple discharge

Indigestion

Breast lump

Abdominal/stomach pain

Hot flashes or night sweats

Abdominal cramping

Coughing

Diarrhea/Constipation

Shortness of breath

Jaundice

Irregular or fast heartbeat

Frequent urination

Chest pain

Painful urination

Swelling of feet or legs

Difficulty holding urine

Pain in legs with walking

Difficulty starting urine

Dizziness/Balance problems

Cold extremities

Fainting/lightheadness

Aching joints

Insomnia

Early morning waking

Agitation/restlessness

Infection

Current Medical Conditions:

Date Diagnosed

No

Physician

continued

181

Medical/Physical Information Sheet continued Current Medications: Prescription Name

Date Prescribed

Physician

Current Psychotropic Medications: Prescription Name

Date Prescribed

Physician

Over the Counter Drugs

Date

Vitamins or Supplements

continued 182

Alcohol: (2 oz equivalent)

a week?

Caffeine: (servings per day?) Coffee

a day? Tea

on weekends?

Cola or other

Other drugs? Allergies:

Medications: Foods: Other:

Dietary Habits: Untrue

Somewhat True

Very True

per week)

Skip meals (frequency:

Little protein and overabundance of sweets or carbohydrates Few fiber-rich foods (fruits, grains, vegetables) Number of calories is low. Number of calories is high Amount of Sleep per Night: Sleep apnea:

hours Use C-PAP

Past Medical Conditions/Problems: Yes

No

Yes

High blood pressure

Liver disease

Heart attack

Colitis

Other heart disease

Arthritis

Stroke/TIA

Blood (e.g., anemia)

Diabetes

Skin

Thyroid

Arthritis

Asthma

Gallbladder

Cancer

Kidney

Stomach

Eye or ear

No

continued

183

Medical/Physical Information Sheet continued Serious Illnesses (What?)

Date

Physician

Delivery Dates

Complications

Injuries:

Surgeries:

Hospitalizations:

Pregnancies or Miscarriages:

continued

184

Past Depressive Episodes: Dates:

through through through through

Past Antidepressant Medications: Prescription Name

Date Prescribed

Physician

Medical Conditions of Family: (parents, grandparents, aunts, uncles, siblings, children) Yes

No

Yes

High blood pressure

Liver disease

Heart attack

Colitis

Other heart disease

Arthritis

Stroke

Blood

Diabetes

Skin

Thyroid

Arthritis

Asthma

Gallbladder

Cancer

Kidney

Stomach

Eye or ear

Depression

Drug/alcohol abuse

No

Date of Last Physical Examination/Medical Evaluation: continued

185

Medical/Physical Information Sheet continued Current Physician(s): Name Address:

Phone Number: Date Release Authorization signed Name Address:

Phone Number: Date Release Authorization signed Name Address:

Phone Number: Date Release Authorization signed

186

Potential Vulnerabilities for Depression Sheet On each line enter the number that corresponds to your answer. True (2)

Somewhat True (1)

False (0)

1. Parents and grandparents had major depression. (G) 2. Sister or brother has had major depression. (G) 3. I have had at least one episode of depression in the past. (H) 4. I have had at least two episodes of depression in the past. (H) 5. In response to stress, I usually get depressed. (H) 6. I do not exercise regularly. (L) 7. In response to stress, I do not exercise regularly. (L) 8. I skip meals or binge eat. (N) 9. There is little protein and an abundance of sweets in my diet. (N) 10. I eat few, if any fiber-rich foods such as fruits, vegetables, and grains. (N) 11. The calories in my diet are extremely high or low. (N) 12. I do not get a regular amount of sleep. (S) 13. I have difficulty going to sleep. (S) 13. I wake frequently during the night. (S) 14. I sleep more than 10 hours per night. (S) 15. I sleep less than 6 hours per night. (S) 16. I have frequent constipation, diarrhea, abdominal pain, or abdominal cramping. (GI) 17. I have frequent nausea or vomiting. (GI) 18. I have difficulty eating solid foods. (GI) 19. I have frequent pain in my muscles, tendons, or joints. (MS) 20. I have frequent knotting or cramping in my muscles. (MS 21. I have been diagnosed with arthritis. (MS, P) 22. I have chronic pain due to physical condition or injury. (P) 23. I have chronic pain due to a medical diagnosis. (P) continued 187

Potential Vulnerabilities for Depression Sheet continued True

Somewhat True

24. I have frequent headaches. (P) 25. I have been constantly tired or fatigued. (F) 26, I have been diagnosed with chronic fatigue syndrome (F) 26. I take sedative medication for sleep. (M) 27. I take narcotic medication for pain. (M) 28. I take medication for high blood pressure. (M) 29. I have been diagnosed with cancer. (Med) 30. I have been diagnosed with diabetes, hepatitis, AIDS. (Med) 31. I have had a heart attack or heart surgery, or have cardiovascular disease. (CV) 32. I drink alcoholic beverages in amounts of more than 1 in a day or 2–3 in a week. (SA) 33. I drink more than 1–2 caffeine drinks per day. (SA)

Potential Vulnerability Areas Enter the sums of your scores for each category below. G H L N S CV

188

Genetic predisposition Historical predisposition Lifestyle contribution Nutritional Sleep disturbance Cardiovascular

GI MS P F M SA

Gastrointestinal Musculoskeletal Pain, chronic Fatigue, chronic Medication Substance use or abuse

False

Medications Log

Prescriber Generic Name Trade Name Purpose

Side Effects Experienced

Date Prescribed

Date Stopped

189

BEAST Questionnaire Yes B1. I feel physically ill, but my doctor has trouble identifying medical problems. B2. I am generally fatigued. B3. I experience muscle aches and pains. B4. I tend to get headaches. B5. I have digestive problems. E6. I am sad most of the time. E7. I cry a lot. E8. There are very few times when I feel happy. E9. Depression is just my way of life. E10. I will be sad forever. A11. I am too tired to do anything. A12. I cannot get started. A13. There is nothing I can do to change my depression. A14. I have no motivation. A15. I am not interested in contact with other people. S16. My situation cannot be changed. S17. My relationships cause me great pain. S18. My relationships are falling apart. S19. My life’s work is a waste of time. S20. I am controlled by situations. T21. I am a loser. T22. I fail more than most people do. T23. This will not work. T24. Nothing will change me. T25. I will never be able to take control of my life.

190

No

Medications Chart

(Do not drink alcohol when taking antidepressants)

191

192 Family

Generic Name

Trade Name

Advantages

Adverse Side Effects

Selective serotonin reuptake inhibitors (SSRIs)

fluoxetine paroxetine escitalopram citalopram sertraline

Prozac Paxil, Seroxat Lexapro, Esipram Celexa Zoloft

Fewer side effects than TCAs or MAOIs

Sexual dysfunction (decreased desire and anorgasmia), nervousness, anxiety, drowsiness, emotional numbing, insomnia, dry mouth, decreased appetite. Severe adverse effects may be discontinuation syndrome and mania. Caution: Discontinuation syndrome so need to taper.

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

venlafaxine nefazodone

Effexor XR, Effexor Serzone (discontinued due to rare cases of liver failure, but still available as nefazodone)

Fewer side effects yet similar to SSRIs. Useful for hot flashes in menopause They can produce sedation, so taken at bedtime

duloxetine desvenlafaxine

Cymbalta Pristiq

Used in neuropathic pain control

Sexual dysfunction (decreased desire, anorgasmia), dry mouth, agitation, insomnia, headache, nausea, vomiting, tremors, and constipation. Effexor may cause tardive dyskinesia. Discontinuation should be tapered. Severe adverse effects include psychosis, mania, and heart arrhythmia. Caution: Discontinuation syndrome so need to taper.

mirtazapine

Avanza Zispin

Fewer sexual side effects

Noradrenergic and specific serotonergic antidepressants (NaSSAs)

Remeron

Fatigue, increased appetite, weight gain, and dizziness. Caution: Don’t take with MAOIs.

Norepinephrine (noradrenaline) reuptake inhibitors (NRIs or NARIs)

Norepinephrine-dopamine reuptake inhibitors (NDRIs)

reboxetine atomoxetine viloxazine maprotiline HCl

Edronax

bupropion radafaxine (presently in clinical trials)

Wellbutrin

Strattera

amitriptyline

193

Lowers the seizure threshold so a high risk of seizures, insomnia, increased heart rate, arrhythmias, myocardial infarction, strokes and drowiness, dizziness, dry mouth, nausea, constipation, urinary retention, blurred vision, muscle stiffness, extreme weight gain, rash, confusion, nervousness, and sexual dysfunction Caution: Don’t take with MAOIs.

Fewer sexual side effects and weight gain. Used with SSRIs for sexual side effects and with mood stabilizers. For seasonal affective disorder and with chemotherapy in breast cancer patients. Used as an aid in smoking cessation.

Lowers the seizure threshold so a high risk of seizures, arrhythmias, hepatotoxicity, severe hypertension. Agitation, anxiety, and insomnia, especially in beginning, may be too sexually stimulating, dry mouth, headache, nausea, tremor, excessive sweating, dizziness, constipation, abnormal dreams, anorexia, weight loss, palpitations, muscle spasms, migraines, paranoia, psychosis, and worsening of depression.

Used in nocturnal enuresis, pain including prophylaxis for migraine headaches

Increased heart rate, drowsiness, dizziness, sunlight sensitivity, dry mouth, nausea, constipation, urinary retention, blurred vision, weight gain, rash, insomnia, confusion, nervousness, and sexual dysfunction Caution: Lethal in overdoses, due to cardiac arrhythmias.

Vivalan Ludiomil Nortrilen

Zyban

Tricyclic antidepressants (TCAs)

Off-label treatment for depression and anxiety Improve concentration and motivation (ADD, ADHD)

Elavil

continued

194

continued Family

Generic Name

Trade Name ∗

Advantages

Adverse Side Effects

Used in chronic pain, enuresis, PMS, ADHD and maybe tinnitus

∗

Inhibits seratonin and norepinephrine reuptake

desipramine nortriptyline

Norpramin

Monoamine oxidase inhibitors (MAOIs)

isocarboxazid phenelzine tranylcypromine procarbazine moclobemide selegiline

Marplan Nardil Parnate Matulane Manerix Eldepryl Emsam (transdermal)

Used rarely, as last resort or history of prior positive response.

Used rarely and as last resort, due to potentially fatal interactions. Contraindications: Foods (with tyramine): aged hard cheeses, air-dried sausages, cured hams, etc., sauerkraut, soy sauce, red wine, tap beer only in very limited quantities, fava beans (broad beans), Chinese pea pods, etc., aged chicken liver, meat that could be spoiled or Marmite yeast extract. Drugs:_(e.g., trazodone, BuSpar, Pamelar, Ludiomil)

Triazolopyridine derivative

trazodone

Desyrel, Molipaxin, Trittico, Thombran, Trialodine, Trazorel

Similar properties as SSRIs. Used for sedative and anxiolytic properties, is often used as a sleep aid and in conjunction with SSRIs.

Caution: Severe adverse effects: Priapism, drowsiness, confusion, sex drive decrease or increase, uncontrollable laughter, nausea, vomiting, suicidal ideations. Discontinuation syndrome, so taper.

Augmenter drugs (used for effects or normal side effects)

buspirone

Buspar

anxiety, agitation, and insomnia

Caution: Don’t take with MAOIs

Pamelar Aventyl Nortrilen

Contraindication: Recent heart attack Don’t take with MAOIs.

Tranquilizers

clonazepam lorazepam

Klonopin Ativan

Antipsychotics

quetiapine rispiridone olanzapine

Seroquel Risperdal Zyprexa

High risk of dependence Sedative quality, used as mood stabilizer, in place of anxielytic, paranoia, psychotic symptoms.

Controversial use. Blurred vision, muscle spasms, restlessness, tardive dyskinesia, and weight gain. Contraindications: NOT with MAOIs

Psychostimulants

amphetamine Adderall, Ritalin dextroampheta mine methylphenidate

Anhedonia, hypersomnia, low motivation, to suppress appetite and sleep

High risk of dependence

Mood stabilizers

Lithium carbonate

Lithium

Standard treatment for bipolar disorder

Thirst, tremors, light-headedness, nausea and vomiting or diarrhea

Anticonvulsants

carbamazepine Sodium

Tegretol Epilim Depakote

Used as a mood stabilizer

Dizziness, blurred vision, coordination problems Contraindicated with liver, kidney, or heart disease. Risk of seizures if abruptly discontinued

Mood stabilizing agent Atypical agent used for schizophrenia as a mood stabilizer or used as adjunct in major depression

Increased appetite, agitation, increased blood sugar, triglycerides, increased blood pressure, headache, weight gain, insomnia, somnolence, akathesia, constipation Severe adverse effects: Serotonin syndrome, tardive dyskinesia

valproate Lamotrigine Atypical agents

Lamictal

Olanzapine/ Fluoxetine combination

Symbyax

Aripiprazole

Abilify

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About the Authors

Mark Gilson, PhD, is the founder of the Atlanta Center, established in 1985. He is former faculty, Department of Psychiatry at the University of Pennsylvania Medical School’s Center for Cognitive Therapy under the direction of Aaron T. Beck, M. D. He is a founding fellow for the Academy of Cognitive Therapy and is also board-certified and Fellow of the American Board of Professional Psychology. He has published a variety of professional articles and book chapters since 1977. Dr. Gilson is current adjunct faculty member with Emory University Department of Psychiatry and Behavioral Sciences and Georgia State University Department of Psychology. Along with his private practice that focuses on the treatment of depression, anxiety, and stress disorders, he also directs the Atlanta Center for Cognitive Therapy’s (ACCT) professional training and certification program that is approved by National Board of Certified Counselors and the American Psychological Association since 1988. The program offers continuing education to psychologists and professional counselors. He also has been producer and radio station manager for college, professional and community radio, including programs that focused on issues in mental health. Arthur (Art) Freeman is Visiting Professor in the Department of Psychology at Governors State University. In addition, he is Clinical Professor at the Philadelphia College of Osteopathic Medicine (PCOM). He is a Distinguished Founding Fellow of the Academy of Cognitive Therapy. He was, for 13 years, the Founding Chair of the Department of Psychology at the Philadelphia College of Osteopathic Medicine. He is a past president of both the Association for Behavioral and Cognitive Therapies (ABCT) and the International Association for Cognitive Psychotherapy. Art was the editor of the Behavior Therapist and the Archive Series and Publications Coordinator for ABCT.

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He is presently Conference and Continuing Education Coordinator for ABCT. He has earned board certification in Clinical Psychology, Family Psychology, and Cognitive Behavioral Psychology from the American Board of Professional Psychology (ABPP). In addition to 100+ book chapters, reviews, and journal articles, he has published over 75 professional books. He has a distinguished international reputation and travels extensively, presenting lectures and providing clinical training. Dr. Freeman serves on the editorial boards of several U.S. and international journals and his work has been translated from English into 14 other languages. M. Jane Yates, PhD, is a clinical psychologist and one of the founding members of the Atlanta Center for Cognitive Therapy in Atlanta, Georgia, where she practices, teaches, and provides clinical supervision and consultation. She is an adjunct faculty member in the Emory University Department of Psychiatry and Behavioral Sciences where she teaches and supervises psychiatric residents. She is a medical consultant in psychology to the Disability Quality Branch of the Social Security Administration. She has authored book chapters and articles in cognitive-behavioral psychotherapy with challenging patients and provides lectures and presentations in cognitive therapy, ethics, and integrating transference and countertransference understanding into the practice of cognitive-behavioral therapy. Dr. Yates has dual clinical credentials. In addition to being a certified cognitive therapist, she is a psychoanalyst and is currently the president of the Atlanta Psychoanaylitic Association. In that role, she has been an advocate for cognitive therapy as an evidenced-based treatment. Sharon Morgillo Freeman, PhD, MSN, PMHCNS-BC, is CEO for the Center for Brief Therapy, PC, and Faculty in the Health Sciences Department at Indiana/Purdue University in Ft. Wayne, Indiana. Dr. Freeman holds a PhD in Sociology and master’s degrees in both Nursing and Psychology. Dr. Freeman is board-certified as an advanced practice clinical nurse specialist, and as an advanced practice addiction registered nurse by the International Nurses Society on Addiction. She is past President of NAADAC, the Association for Addiction Professionals. She serves on the Medical Board and Board of Directors of The Recovery Center and the Alcohol Abuse Deterrent Program in Fort

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Wayne, Indiana. She is certified in Cognitive Therapy by the Academy of Cognitive Therapy. Dr. Freeman serves on the Board of Directors for the International Association for Cognitive Psychotherapy. In addition to authoring numerous articles, chapters, and books, Dr. Freeman has lectured as an invited keynote or primary presenter to medical, nursing, and psychological audiences in more than 17 countries.

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