Transcript Cognitive Behavioral Therapy for Depression– an introduction

Dr Kate Hardy, Clin.Psych.D
Post Doctoral Fellow
Prodromal Assessment, Research and Treatment Team (PART), UCSF
[email protected]
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Develop a shared formulation of depression
with a client
Elicit negative automatic thoughts with a
client
Use the downward arrow technique to explore
core beliefs
Apply cognitive and behavioral interventions
in the treatment of depression
Know where to locate further reading and
information regarding CBT for depression
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Persistent sad, anxious or "empty" feelings
Feelings of hopelessness and/or pessimism
Feelings of guilt, worthlessness and/or
helplessness
Irritability, restlessness
Loss of interest in activities or hobbies once
pleasurable, including sex
Fatigue and decreased energy
Difficulty concentrating, remembering
details and making decisions
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Insomnia, early–morning wakefulness, or
excessive sleeping
Overeating, or appetite loss
Thoughts of suicide, suicide attempts
Persistent aches or pains, headaches,
cramps or digestive problems that do not
ease even with treatment
From NIMH website
(http://www.nimh.nih.gov/health/publications/depression/completepublication.shtml
)
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NICE guidelines – mild vs moderate
NIMH – ‘By teaching new ways of thinking and
behaving, CBT helps people change negative
styles of thinking and behaving that may
contribute to their depression’.
NIMH also recommends IPT
NIMH suggests that ‘for mild to moderate
depression psychotherapy may be the best
treatment option’
Early Experiences
Core beliefs
Underlying assumption
Critical incident
Activate assumptions
Thoughts
Feelings
Behaviour
Physical
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Early experiences lead people to develop core
beliefs
From core beliefs unhelpful assumptions are
generated that organize perception and
govern behavior
Critical incident triggers the assumptions
Leading to negative automatic thoughts
(NAT’S) which have knock on effect to mood,
behavior and physiology
Environment
Thoughts
Biology
behavior
Mood
Early Experiences
Core beliefs
Underlying assumption
Critical incident
Activate assumptions
Thoughts
Feelings
Behaviour
Physical
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Socialize to the model
Previous experience of therapy and
expectations
Contracting
Assessment
Problem list
Goal setting
Agenda setting
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Specific
Measurable
Achievable
Realistic
Time limited
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I want more friends
I want to stop worrying
To stop thinking negatively about everything
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Magic/miracle question (solution focused
therapy)
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If I had a magic wand and I could use that wand to change
everything for you over night so that everything was better for
you what would be the first thing that you would notice in the
morning that would tell you things had changed?
Helps client to start to think of life without
the problem
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Asking client to rate on a scale the worst they
have ever been
The best they have ever been
Where they would like to be on that scale
What is realistic
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Aim is to encourage the client to notice what
is going through their mind when they have a
strong reaction to a situation
Link this thought to an emotion and rate the
emotion
Thought is an interpretation of the situation
and it is this thought that governs the
emotional response
The thought with the highest emotional
rating is the hot thought (NAT)
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Technique to identify underlying assumptions
and core beliefs that drive the NAT’s
Explore what the NAT means to the individual
Can also ask the client to complete the
following statements:
 I am
 Others are
 The world is
I am going to be rejected again
(If that were true what would that mean )
I’ll never have close relationship
If I get close to people I get hurt
I need to protect myself
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50 year old woman
Married (second marriage)
Five children (three at home)
Previous CBT for depression with Graduate
Mental Health Worker
Reported that she found this helpful but
wants additional sessions as depression has
returned
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Was adamant that she wanted to explore her
childhood to help explain her current
problems
Didn’t think she could improve long term
without this
Had liked CBT previously hence referral
currently
Not on medication for depression at that
point
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Working as a support teacher for children
with learning disabilities
Living with three of her children and disabled
husband
Sixteen year old son with severe autism and
behavioral difficulties
Poor physical health
Reported difficult relationship with husband
Past suicidal ideation and some during the
sessions but no plan
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Recurrent relapse of depression
Not happy at work
Feels ‘walked all over’ by family and
colleagues
Feels like she is taken for granted by friends
and family
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To voice disagreements in a meeting at work
and reduce worry about this from an 8 to a 3
To spend thirty minutes a day doing
something that she wanted to do (listening to
music, reading)
To identify triggers to low mood and keep
mood above a ‘4’ for 80% of the time
To understand the origins of recurrent low
mood and links to current difficulties
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Impoverished area
Never finished school – left school early to
take care of mentally ill relative
Father had diagnosis of schizophrenia and
was physically violent to Diana’s mother
Diana observed physical violence but was
never physically abused herself
Early Experiences
Observe physical violence
Core beliefs
I need to keep quiet
Underlying assumption
If I speak up I will make the situation worse
Critical incident (s)
Activate assumptions
Thoughts
I can’t get my point across
No one likes me/listens to me
I can’t say anything
Feelings
Anxious
Depressed
Upset
Physical
Nauseous
Heart racing
Behavior
Keep quiet
Leave the room
Avoid people at work
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Behavioral activation
1. Monitor activities through a daily diary
2. Rate each activity out of 10 for pleasure and mastery
(sense of achievement)
3. Rate level of depression
4. Schedule activities based on information from the
diary
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Thought challenging
1. Use thoughts identified on thought record and rate
how much believe the thought
2. List all evidence that supports the thought
3. List all evidence that suggests the thought is not
true 100% of the time
4. Based on the evidence re –rate how much you
believe the original thought, an alternative thought
and re-rate emotion
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Behavioral experiments
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Identify belief to be tested
Rate conviction in this belief
Design experiment
Identify any problems with the experiment and ways
to overcome it
Record expected outcome
Usually do experiment as homework but can be
done in session
Record actual outcome
Create alternative belief based on new evidence
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Behavioral experiment – when disagree in a
meeting speak out and observe what
happens
 Prediction that people would not speak to her
following this (rate this belief)
 Observed that people spoke to her just as much
after the meeting (re-rate belief and create new
belief based on this evidence)
 Also found that people appreciated her input
(further evidence)
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Survey
 Asked children how they knew she loved them and
how does she know they love her
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Consideration of evidence – judge and jury
 Rather than instantly believing NAT – considered evidence for
and against the thought.
 Presented this as from perspective of prosecution and defense
 Final decision up to the judge (Diana)
 Decision to accept the thought or throw it out of court
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Relaxation
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Using information sheet try to develop a
formulation for Sue (in pairs)
Consider her early experiences and what
beliefs these may have given rise to
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Core Beliefs
 I need the help of others
 I am not good enough
 Other people will always let me down
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Assumptions
 I need to be perfect to be accepted
 If I am not passive/accepting I will be rejected
 I have to be careful or people will disappoint me
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In pairs think about what interventions could
be developed with Sue
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Tallying – surveyed how often she told James
she loved him (found it was very frequent)
Developed goal to reduce this and set up
behavioral experiment
Behavioral experiment to reduce contact with
parents
Role play to practice more assertive
interaction with parents
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Greenberger and Padesky (1995) Mind over Mood
Fennell M.J.V (1989) Depression. In K. Hawton, P.M.
Salkovkis, J. Kirk & D.M. Clark (Eds) Cognitive
Behaviour Therapy for Psychiatric Problems: A
practical guide.
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Bennett-Levy, J. et al (2004) Oxford guide to
behavioural experiments in Cognitive Therapy
Mood gym (http://moodgym.anu.edu.au)
http://medschool.ucsf.edu/latino/manuals.aspx#G
roupCognitiveBehavioralTherapyofMajorDepression