Transcript CBT skills for Depression

CBT for Depression
Richard Moore
Clinical Psychologist
Cambridge Specialist Depression Service
Outline of session
• The cognitive model of depression
• Describe behavioural and cognitive
techniques
• Give ‘flavour’ of therapy: videos, ?practice
Diagnosis of Major Depression
(DSM)
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At least five of the following symptoms:
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depressed mood
loss of interest or pleasure
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appetite or weight change
change in sleep
lowered energy levels and fatigue
agitation or retardation
excessive guilt or worthlessness
poor concentration or indecision
recurrent thoughts of death or suicide
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Symptoms most of the time over two week period
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Significant distress or impairment in social/ work function
Outcome of CT for depression
• CT is effective as acute treatment
-early studies (eg Rush et al, 1977)
-NIMH study (eg Elkin et al 1989)
-recent rigorous studies (De Rubeis et al
2005)
• CT can help to prevent relapse
-early uncontrolled studies (eg Simons 1986)
-controlled studies (e.g. Blackburn and
Moore, 1997; Hollon et al, 2005)
‘Cure’ rates in CT for depression
• Rate of response after 16-20 weeks about 60%
(eg DeRubeis et al 2005)
• Rate of relapse over the year after treatment
about 30-40% (eg Hollon et al 2005)
• Sustained response over acute treatment and
follow-up 27% in ADM and 37% in CT
RCT of Specialist Care for Chronic
Depression
• Comparison of specialist service with treatment as usual
(2° care)
• Specialist service is psychiatry/ADM, psychological
therapy and CPN… at once / intensive … for 12 months
• Patients with primary depression, treated in 2° care> 6
months, HRSD > 16
• Compare outcome over 1+1 years: effectiveness and
cost-effectiveness
• Funded by CLAHRC in Cambridge/Nottingham
Foundations of Cognitive Therapy
(Beck et al 1979)
• Therapeutic relationship
• Structure and style of therapy
• Cognitive model
Style of CBT
• Collaborative
• Therapist can be active/directive
• Questioning is vital tool
• Balance with understanding/empathy
Structuring the session
• setting an agenda
• summarising throughout and at end
• feedback at end
• homework/ self-help
Cognitive behavioural model of
depression
• What are the crucial thoughts/behaviours
in depression?
• Vicious circles (The worse you feel…)
Levels of Cognition
• Content of thinking: automatic thoughts
• Process of thinking: errors or biases
• System of thinking: underlying attitudes,
beliefs, assumptions
Negative Automatic Thoughts
• pop into mind
• accessible, can be reported
• ‘hot’, fit with feelings
• triad about self/world/future
Negative Automatic Thoughts
• Self
useless
inadequate
• World
demanding
unpleasant
• Future
bleak
hopeless
Cognitive Errors/Biases
• Arbitrary inference-jumping to conclusions in the absence of
information or facts
• Selective abstraction- mental filter that singles out negative details
and ignores positive
• Overgeneralisation- seeing a general pattern from particular
negative events
• Personalisation- assuming personal responsibility where other
factors are involved
• All-or nothing thinking- seeing things as black or white with no
middle ground
• Magnification/minimisation- exaggerating shortcomings while
playing down strengths
Underlying beliefs
• rules, assumptions and beliefs that guide
appraisal and evaluation of experience
• based on past (early) experience
• interpretation = event + beliefs
• conditional assumptions vs unconditional beliefs
Beliefs in depression
• conditional beliefs and assumptions:
I must be liked by everybody
If I don’t succeed, I am useless
If I lose control, I will never regain it
I should be able to do anything without any
help from others
• unconditional beliefs:
I am a failure
I am unlovable
Two major themes in depression
• Sociotropic
-depends on relationships with others
-needs acceptance, approval and validation
-vulnerable to social disruptions
• Autonomous
-depends on satisfying own independence, attainments and
interests
-needs to master and control own environment
-vulnerable to frustration by others/ personal shortcomings
Vicious circles
• The worse you feel, the more negative
your thoughts…
• The more negative your thoughts, the
worse you feel…
Another vicious circle
• Negative thinking reinforces withdrawal/
avoidance
• Effects of avoidance back up negative
thinking
Behavioural theories of depression
• Depression due to lack of ‘response
contingent positive reinforcement’
• Depression viewed as reduction of operant
behaviour (i.e. passivity, inactivity)
Behavioural theories of depression
• engage in fewer ‘reinforced’ pleasant activities
(Lewinsohn 1974)
• extinction of behaviour due to loss of reinforcers
(Skinner 1953, Ferster 1973)
• loss of reinforcer effectiveness ie rate activities
as less enjoyable (Costello 1972)
• lack of social skills (Lewinsohn 1974)
Cognitive Formulation
• develop individual formulation
• guides treatment plan
• anticipate/deal with problems
Case formulation
• How is each factor (situations, emotions, NATs,
beliefs…) affected in this case?
• How do the different factors fit together?
• What cognitive and behavioural processes are
maintaining the problems now?
• What might be the underlying beliefs/schemas?
• How do cognitive and behavioural processes
link the underlying schemas to the problems?
Formulation example
• Symptoms: low mood + frustration, poor sleep, low energy, poor
concentration
• Current problems:
• Automatic thoughts (triad) and cog biases:
• Previous problems (e.g triggers of past episodes):
• Formative experiences (e.g. family, peers):
• Themes/attitudes/beliefs:
• Suitability for CBT?
Selling the model
• Explain links of feelings/thoughts/behaviour
• Use standard examples eg noise in the night
• Use recent examples of upset
• Aim of therapy to reality test thoughts
Rationale for behavioural
techniques
• to identify links between mood and behaviour
• to improve mood by increasing activities
(engagement)
• to identify negative thoughts affecting activities
• to test negative thoughts and beliefs through
activities
Behavioural techniques in
depression
• Diary of activity (hour by hour)
• Monitoring mood or Mastery and Pleasure
• Scheduling activities
• Graded task assignment
Scheduling activities
• Separate planning from execution
• Find out potential activities
• ‘to do’, pleasure
• what did before depressed
• Lists/ sublists
• Plan activities hour by hour or am/pm/eve
Graded task assignment
• Breaking down tasks into chunks
• Setting limits on task (time, amount)
• Choose easiest tasks first
• Allocate time slot
Using activity schedules to question
NATs
Thought
Test
“I never get anything done”
Activity diary
“Nothing makes me feel
any better”
Mastery and pleasure
ratings
“I can’t enjoy anything
any more”
Schedule pleasant
activities
“I can’t do it”
Graded task assignment
Identifying automatic thoughts:
principles
• Be specific
• Home in on emotion
• Label thoughts elicited
Identifying automatic thoughts:
techniques
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“what went through your mind?”
moments of emotion in session
action replay of times when upset
ascertain the meaning of events
use imagery/role play
Thought monitoring
• Helps to build awareness
• Labelling NATs in session
• Counting NATs can be helpful
• Thought diaries eg 3 column diary
Questioning Automatic Thoughts:
Principles
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home in on affect
ask questions the patient can answer
listen to the answers
start with what supports the patient’s view
be open-minded
look for the patient to be positive
Four crucial lines of questioning
• What’s the evidence?
• What is an alternative viewpoint?
• Scaling
• Carving up the blame pie
What’s the evidence?
• evidence for and against
• broader perspective
• past and present
What is an alternative viewpoint?
• how would you view this if you were well?
• what would you say to a friend?
• how will you view it in a week/month/year?
Scaling
• What would someone who was 100%
totally (bad) be like?
• What is someone who is not at all 0%
(bad) like?
• Where realistically would you put yourself
on this scale?
Carving up the blame pie
• Show the patient’s view of taking all the
blame pie for the situation
• Elicit (collaboratively) other factors
contributing to the situation
• Assign a proportion of the blame pie to
those other factors
• See how much of the blame pie is really
left to the patient
Goals of questioning
• Reduce belief in negative view/build
positive view
• Be more accepting of negative experience
• Find new ways to handle problems
Identifying underlying assumptions
• Looking for common themes
• Downward arrow technique (“inference chaining”)
-what would that mean to you?
-what’s the worst thing about that?
• Congruence with early experiences
• Dysfunctional Attitudes Scale (Weissman & Beck, 1978)
Modifying Assumptions
• examine evidence for and against
• weigh up advantages and disadvantages
• discuss the basis of self-worth
• behavioural experiments
-test out going against belief
-acting on basis of alternative
assumption
Beliefs/schemas
• Fundamental/gospel truth
• Possibility that ‘belief’ not ‘truth’
• prejudice model (Padesky, 1990)
• self-fulfilling prophecy
• Undermine evidence supporting belief
• Build more helpful alternative
• positive ‘data logs’
I can see it’s irrational but I still feel
the same
• Does it still feel exactly the same?
• Is there “proof” maintaining the belief?
• Are behaviours maintaining the belief?
• Is any alternative being put into practice?
Good Cognitive Therapy
• …is not purely rational
• …addresses specific situations
• …addresses patient’s behaviour
• …addresses ‘real’ problems
• …promotes enduring change
Rumination in depression
• repetitive focus of attention and thinking
on symptoms and problems
• rumination can intensify and prolong
depressed mood
• rumination as a processing style perceived
as beneficial
• viewed as solving problems, relieving
upset, averting criticism
Intervening in suicidal ideation
• Reasons for dying… and for living
• Undermine hopelessness
• Problem solving
• Plan of activity