Ct depression abasseya

COGNITIVE THERAPY
OF
DEPRESSION

Dr. Reham Abdel-Samie Aly
MD Psychiatry
Fellow of Arab Board of Psychiatry
Academy of Cognitive Therapy Diplomate & Member

The Beginning

A ARON T. BECK

A. JOHN RUSH

BRIAN F. SHAW

GARY EMERY

Introducing the authors

 “The early origins of my formulations regarding
cognitive therapy of depression are not completely
clear to me at present.
 As far as I can recall the first stirrings became manifest
in my venture beginning in 1956 to validate certain
psychoanalytic concepts of depression.
 I believed that these psychoanalytic formulations were
correct but had failed to gain wider acceptance
because of certain natural "resistances" of the
academic psychologists and psychiatrists,
attributable, in part, to the lack of supporting
empirical data.

Contents of the Book
 1. An Overview 1
 2. The Role of Emotions in Cognitive Therapy 34
 3. The Therapeutic Relationship: Application to Cognitive Therapy 45
 4. Structure of the Therapeutic Interview 61
 5. The Initial Interview 87
 6. Session by Session Treatment: A Typical Course of Therapy 104
 7. Application of Behavioral Techniques 117
 8. Cognitive Techniques 142
 9. Focus on Target Symptoms 167
 10. Specific Techniques for the Suicidal Patient 209
 11. Interview with a Depressed Suicidal Patient 225
 12 Depressogenic Assumptions 244
 13. Integration of Homework into Therapy 272
 14. Technical Problems 295
 15. Problems Related to Termination and Relapse 317
 16. Group Cognitive Therapy for Depressed Patients
 17. Cognitive Therapy and Antidepressant Medications 354
 18. Outcome Studies of Cognitive Therapy

Roots of CBT
 The work of Ellis (1957, 1962, 1971, 1973)
provided a major impetus in the historical
development of CBT.
 Ellis links the environmental or Activating
event (A) to the emotional Consequences
(C) by the intervening Belief (B).
 Rational-Emotive Psychotherapy aims at
making the patient aware of his irrational
beliefs and the inappropriate emotional
consequences of these beliefs.
 Rational-Emotive Psychotherapy is
designed to modify these underlying
irrational beliefs.

Philosophical Origins

 "Men are disturbed not by things but by the views which
they take of them." Epictetus

 Symptoms & affect are based on unconscious ideas. Freud

 “We do not suffer from the shock of our experiences—the
so-called trauma—but we make out of them just what suits
our purposes.” Alfred Adler

 A number of other writers whose work emerged from or
was influenced by the psychoanalytic tradition have
contributed important concepts to the development of
cognitive psychotherapy; Sullivan (1953), Piaget
(1947/1950, 1932/1960) , Arnold Lazarus (1972)

General Assumptions
1. Perception & experiencing are active processes which involve
both inspective & introspective data.
2. The patient's cognitions represent a synthesis of internal &
external stimuli.
3. How a person appraises a situation is generally evident in his
cognitions .
4. These cognitions constitute the person's "stream of
consciousness", which reflects the person's configuration of
himself, his world, his past & future.
5. Alterations in the content of the person's underlying cognitive
structures affect his or her affective state & behavioral pattern.
6. Through psychological therapy a patient can become aware of his
cognitive distortions.
7- Correction of these faulty dysfunctional constructs can lead to
clinical improvement.

A N OVERVIEW

SECTION I

The Cognitive Model of Depression
Beck, 1976

 From systematic clinical observations &
experimental testing. (Beck 1963,1964,1967)
 Interplay of a clinical & experimental approach
allowed for a progressive development of the
model & of the psychotherapy derived from it.
 Postulates 3 specific concepts to explain
depression;
 Cognitive triad
 Schemas
 Cognitive errors (faulty information processing).

The Cognitive Triad
3 major Cognitive Patterns which guide the patient in
his view of himself, his current experiences & his
future.

1st
Patient’s negative view of self

 Sees himself defective, inadequate,
diseased or deprived.
 Attributes unpleasant experiences to
psychological, moral or physical
defect.
 Believes he lacks essential attributes
to attain happiness & contentment.

2nd
patient's tendency to interpret ongoing
experiences in a negative way

 “The world present obstacles in reaching his
goals”.

 Misinterprets interactions as representing
defeat/deprivation.

3rd
Negative view of the future

 Anticipates that his suffering is indefinite.

 Expects unremitting hardship, frustration &
deprivation.

 Expectation of failure.

Cognitive formulation of depressive
symptoms
Clinical Application

The cognitive model views signs & symptoms
of the depressive syndrome as consequences
of the activation of the negative cognitive
patterns.
For example, if the patient incorrectly thinks
he is being rejected, he will react with the
same negative affect (e.g., sadness, anger)
that occurs with actual rejection.
If he erroneously believes he is a social
outcast, he will feel lonely.

Motivational symptoms

 Paralysis of the will results from the patient's
pessimism & hopelessness:
 If he expects a negative outcome, he will not commit
himself to a goal or undertaking.
 Suicidal wishes:
 as an extreme expression of the desire to escape from
insoluble problems or an unbearable situation.
 The depressed person may see himself as a worthless
burden & consequently believe that everyone, himself
included, will be better off when he is dead.

Increased dependency

 Because the patient sees himself as inept & helpless
& unrealistically overestimates the difficulty of
normal tasks, he expects his undertakings to turn
out badly.

 Thus, the patient tends to seek help & reassurance
from others, whom he considers more competent &
capable.

Physical symptoms

 Apathy & low energy may result from the
patient's belief that he is doomed to failure in
all efforts.

 A negative view of the future (a sense of
futility) may lead to "psychomotor
inhibition."

Schemas
(Structural Organization of Depressive Thinking)

Schemas
 Why a depressed patient maintains his pain-
inducing & self-defeating attitudes despite
objective evidence of positive factors in his life?!
 The term "schema" designates stable cognitive
patterns.
 It is the basis for molding data into cognitions.
The Matrix
 The kinds of schemas employed determine how
an individual will structure different experiences.

Schemas (cont.)

 Schema may be inactive for long periods of time but
is energized by specific environmental inputs (e.g.,
stressful situations).
 In depression, patients' conceptualizations of
specific situations are distorted to fit the prepotent
dysfunctional schemas.
 Appropriate schema is upset by the intrusion of
overly active dysfunctional idiosyncratic schemas.
 As these idiosyncratic schemas become more active,
they are evoked by a wider range of stimuli which
are less logically related to them till the patient loses
his voluntary control over his thinking processes & is
unable to invoke other more appropriate schemas.

Schemas
Situation

Stimuli

selective attention

specific stimuli

Conceptualization

Cognitive symptoms & Schemas
 Schemas  idiosyncratic  completely
dominates thinking preoccupation with
preservative , repetitive –ve thoughts 
 inability to concentrate on external stimuli e.g.
reading
 or engage in voluntary mental activity e.g. problem
solving & recall.

 I.e. the Idiosyncratic Cognitive Organization has
become Autonomous & independent to external
stimuli.

Faulty Information Processing

Faulty Information Processing

 Systematic errors in the thinking of the
depressed person maintain the patient's belief in
the validity of his negative concepts despite the
presence of contradictory evidence.
 Include:
 Arbitrary Inference
 Selective Abstraction
 Overgeneralization
 Magnification & Minimization
 Personalization
 Absolutistic, Dichotomous Thinking (

Types of Faulty Information Processing

 Arbitrary Inference ;  Selective abstraction ;
 drawing a conclusion in  consists of focusing on a
the absence of evidence detail taken out of
to support the context, ignoring other
conclusion or when the more salient features of
evidence is contrary to the situation &
the conclusion. conceptualizing the
whole experience on the
basis of this fragment.
 a response set
 a stimulus set

(cont.)
 Overgeneralization;  Magnification &
 drawing a general rule or minimization;
conclusion on the basis  errors in evaluating the
of one or more isolated significance or
incidents & applying the magnitude of an event
concept across the that are so gross as to
board to related & constitute a distortion.
unrelated situations.

 a response set
 a response set

(cont.)
 Personalization ;  Absolutistic
 proclivity to relate external (dichotomous thinking);
events to oneself when  tendency to place all
there is no basis for experiences in one of two
making such a connection. opposite categories; for
example, flawless or
defective, immaculate or
filthy, saint or sinner. In
 a response set describing himself, the
patient selects the
extreme negative
categorization.
 a response set

Thinking disorder in depression

 Depressed persons are prone to structure
their experiences in relatively primitive ways.

 “Primitive" vs. “Mature" modes of organizing
reality.

Thinking disorder in depression

Primitive thinking Mature thinking
 Non-dimensional & Global;  Multidimensional.
 I am fearful.  I am moderately fearful, quite
generous, & fairly intelligent.
 Absolutistic & Moralistic;  Relativistic & non-judgmental.
 I am a coward.  I am more fearful than most people I
know.
 Invariant;
 I always have been & always  Variable;
will be a coward.  My fears vary from time to time &
from situation to situation.
 “Character Diagnosis”;  “Behavioral Diagnosis”;
 I have a defect in my character.  I avoid situations too much & I have
many fears.
 Irreversibility ;
 Since I am basically weak,  Reversibility;
there's nothing that can be done  I can learn ways of facing situations &
fighting my fears.
about it.

Predisposition to & Precipitation of Depression

A Reciprocal Interaction Model
“A person’s behavior influences other people whose
action in turn influence the individual”. Bandura 1977

The Reciprocal Interaction Model

 A person slipping into depression may withdraw
from significant other people. Thus alienated,
the "significant others" may respond with
rejections or criticisms, which in turn, activate or
aggravate the person's own self-rejection & self-
criticism. The resulting negative
conceptualizations lead the patient to further
isolation.

 Thus the vicious cycle can continue until the
patient is so depressed that he may be
impervious to attempts by others to help him &
show him love & affection.

Prerequisites for Conducting CT
1- Know your enemy.
2- Expect the worst.
3- Master your craft.
4- Be genuine.

1- Know your enemy
 Must have a solid understanding of the clinical syndrome of
depression.

 “Treat the patient rather than the disorder”?!!
 1- specific symptoms to differentiate from different disorders.
 2- has a particular course.
 3- lethal complication (suicide).
 4- successful somatic treatment (psychopharmacology & ECT).
 5- body of evidence favors a biological derangement.
 6- a strong hereditary determinant.
 7- specific cognitive distortions & underlying assumptions.
 8- determine the ppt factor (actual or imagined loss vs. threat or
danger).

Warning

 Inexperienced clinician may fix his attention
on one facet of depression & ignore others
e.g. associated psychotic symptoms &
proudly report a change in one area e.g.
improved interpersonal relations, increased
activity level, or an apparent reduction of
sadness.
 Within a few days the patient committed
SUICIDE.

2- Recognize the suicidal patient

 Even a mildly depressed patient may commit
suicide.
 Suicide is NOT uncommon during
psychotherapy.
 Act fast:
 Notify patient’s family
 Hospitalization
 Medication & ECT
 Prompt psychological intervention.

3- Master your craft

 The aspiring cognitive therapist must be 1st a
good psychotherapist.
 Necessary characteristics:
 Have the capacity to respond to your patient with
concern, acceptance & sympathy.
 Therapists with diverse backgrounds can
successfully conduct CBT e.g.
 Psychodynamic; empathetic, sensitive & skillful.
 Behavioral therapists; well qualified in BT
techniques

4- Be genuine

 To achieve good results in CBT be
knowledgeable, warm, empathetic,
accepting, have a clear understanding of the
cognitive model of depression, grasp the
concept of CT .

 Earn formal training including supervision;
 a range of six months training to 2 years is enough
to reach criteria of competency.

Limitations of applicability

 Specific kinds of depression.
 Presence of ‘borderline’ characteristics.
 Patient’s characteristics;
 Educational level,
 Attitudes towards psycho- vs. pharmaco-therapy,
 Psychological-mindedness,
 Ego-strength.

Warning

 Therapy should be confined to the kinds of
patients who have been shown by research
studies to be responsive to this approach.
 Effectiveness of therapy was demonstrated
with ONLY unipolar, nonpsychotic,
depression.
 For severe or bipolar or suicidal patients apply
standard procedures (hospitalization &
somatic therapy).

Warning (cont.)

 When is CBT preferable to medication:
 Patient refusing medication,
 Prefers psychological approach in hope that it will
reduce his proneness to depression,
 Has unacceptable side effects or C.I. to
medication,
 Has proven refractory to somatic treatments.

Common Pitfalls in Learning CT
Common defects & errors in the therapeutic
approach of trainees!

1- Slighting the therapeutic approach

 Forgets the importance of establishing a
sound therapeutic relationship with the
patient.
 The therapist must never lose sight of the fact
that he is engaged with another human being in a
very complicated task.

Safeguard

 Be particularly sensitive to:
 a. The importance of discussion & expression of
the patient's emotional reactions.
 b. The patient's own habitual style of
communicating.
 c. be very active at times & relatively restrained at
others.
 d. some patients require considerable coaching,
others require encouragement to take the
initiative.

2- Being Stylized, Erratic, or Overly
Cautious

 Trainees may be so eager to master the technical
aspects that they parrot their role models ("The
Masters") instead of integrating the therapeutic
approach into their own natural style.
 At the other extreme, the therapist may stretch
the elasticity of the cognitive model to "try out"
whatever particular techniques appeal to him
without regard to their appropriateness for this
particular patient at this particular time.

Safeguard

 Obtaining feedback from the patient
regarding his understandings of the
therapist's communications & any
counterproductive reactions he may have to
the therapist's manner, techniques, or
suggestions .

3- Being Overly Reductionist & Simplistic

 Many trainees believe cognitive therapy
involves only getting people to recognize &
correct their negative thinking.

 The inexperienced therapist may attempt to
conduct therapy "from a cookbook."

Safeguard

 The therapist needs to tread the line between
being overly concrete & overly abstract;
atomistic vs. global.

 Cognitive therapy is a holistic approach but it
is applied in a sequence of discrete, readily
understandable steps.

4- Being Overly Didactic or Excessively
Interpretive

The use of questions is an important part of
cognitive therapy. It may be easy for the
therapist to point out that the patient has
distorted his experiences, that there is an
intervening thought between an event & an
emotional experience.
But very little progress may occur.

Safeguard

 Ask questions that open up the patient's closed logic
by using an inductive approach.
 Encourage the patient to practice a self-questioning
behavior later when he is without a therapist e.g.
 "What is the evidence?"
 "What is the most adaptive thing for me to do right now?"
 Enable the patient to learn to recognize & test his
hypotheses, to develop a healthy empiricism that
serves as a safeguard against forming unrealistic
conclusions.
 Assume an educative role with the patient e.g. to
explain characteristics of depression & cognitive
therapy.

5- Reacting Negatively to Depressed
Patients
 working with depressed patients is often
hard, tedious work.
 get caught up in the patient's belief that his
life is hopeless & thus give up on the patient.
 label the patient as being resistant & make a
motivational interpretation of the patient's
behavior & thus react to the patient on the
basis that he is being manipulated.

Safeguard

 Attempt to empathize with the patient.

 Understand the patient's "resistance" as
inevitable consequence of the way he
constructs reality.

6- Accepting “Intellectual Insight”

 To be misled by the patient's statements that
he believes the therapist's formulations
"intellectually" but not "emotionally."
 What is "real" to the patient is his own
belief—not the therapist's declarations.
 When an individual holds an important belief,
he usually "trust" his subjective feeling that
the belief is right.

Safeguard

 Allow the patient to gradually integrate the
therapist's idea into his belief system.

 This is accomplished best through Empirical
(practical) Demonstration.

1- Importance of Collaborative
Enterprise with the Patient

 The more the therapist & patient work
together, the greater the learning experience
for both.
 The joint effort engenders a cooperative spirit
& a sense of exploration & discovery.
 This enhance motivation & help to overcome
the many obstacles.

2- Value of Capitalizing on the Variations &
Fluctuations in the Patient’s Depression

 When the patient shows an improvement, the
therapist should encourage him to pinpoint what
methods (if any) contributed to the
improvement.
 Exacerbations of symptoms or relapses should
be anticipated and "welcomed" as a valuable
source of information for exploring the factors
leading to intensification of depression and a
valuable opportunity for the patient to practice
his techniques for dealing with these problems.
 “Turn every disadvantage into an advantage."

3- Continuing Emphasis on Self-
Exploration

 The concentration on exploring the meaning
of events throughout the course of therapy &,
especially, after termination, should be
encouraged.

4- “State-Dependant Learning”

 Patients learn best to analyze & deal with
their difficulties when their problems are
"hot."
 What a person learns in a particular state is
more likely to generalize to that specific state
than to other states.
 For this reason, it is sometimes advisable to
attempt to "recreate" a quiescent situation
during a therapy session.

5- Collaboration of Significant
Others

 Sometimes the active collaboration of a
family member or friend may be indicated.

 The "auxiliary therapist" can be trained to
implement specific therapeutic strategies in
the home situation.

A TYPICAL COURSE OF THERAPY

SECTION II

OVERVIEW

 Initially, the therapist presents a rationale for
cognitive therapy & discuss the patient's reaction to
the model.
 Prior to the first treatment session, the therapist
send the patient a booklet about Depression, with a
request that she read it to assist with this aspect of
treatment.
 Therapy then center on the patient's symptoms with
initial attention to behavioral & motivational
difficulties.
 Then emphasis is directed to the content & pattern
of the patient’s thinking.

OVERVIEW (cont.)

 In the later sessions, therapist & patient discuss the basic
assumptions that were viewed as resulting in the
patient’s vulnerability to depression.
 Experience indicates that the moderately to the severely
depressed patients require twice-weekly sessions
initially.
 The frequency and duration of therapy has to be
adjusted to the needs of the individual case;
 Protocol call for a maximum of 20 sessions over a 15-week period.
 On the average, patients receive therapy twice a week for 4
weeks & then once a week for 7 weeks.
 Therapist should be flexible in "tapering off' therapy (e.g., to bi-
weekly, monthly, etc.).

Eliciting Essential Information

Elicit information regarding the patient's;
(a) diagnosis,
(b) past history,
(c) present life situation,
(d) psychological problems,
(e) attitudes about treatment, &
(f) motivation for treatment.
Give the patient some objectivity regarding the
particular disorder. This objectivity in itself is
often quite reassuring.

Mental Status Examination

 It is crucial that the therapist make appropriate
evaluation as to:
 whether or not the patient is psychotic.
 whether the patient is suicidal.
 "organic" problems such as brain damage, physical
illness simulating depression, mental deficiency, etc.

 Thus therapist needs to have a strong grounding
in psychiatric evaluation & diagnosis & a
reasonable knowledge of medical disorders.

Therapeutic Goals of the Initial
Interview
 A main therapeutic goal of the first interview is
to produce at least some relief of symptoms;
 Reduce patient’s suffering,
 Satisfies the therapist's desire to help another person
in a meaningful way.
 The symptom relief helps to increase rapport,
therapeutic collaboration, & confidence in the efficacy
of the therapy.
 Make the patient more optimistic & the reinforcing
effect of having "worked through" a particular
problem.
 Stimulates the patient to do his homework between
sessions.

Therapeutic Goals of the Initial
Interview (cont.)
 The most effective way to reach the immediate
therapeutic goal & provide a rational basis for
reassurance is to attempt to define a set of problems
& demonstrate to the patient some strategies for
dealing with these problems.
 The technical application of the strategies should
(ideally) begin during the interview &, be carried out
by the patient after the interview is completed.
 Any "success experience" by the patient— even
achievement of the task of isolating a problem &
viewing it objectively during the interview—is likely
to give him an increased sense of mastery.

Selecting Target Symptoms

 The target symptom is “any of the components of
the depressive disorder that involves suffering or
functional disability”.
 It is difficult to stipulate in advance which problems
should be selected during the first interview .
 The therapist (with the assistance of the patient)
makes a determination as to which of the target
symptoms should be addressed on the basis of many
factors:
 a. Which are the most distressing to the patient?
 b. Which are most amenable to therapeutic intervention?

Selecting Target Symptoms (cont.)

 Target symptoms may be broken down into the following
categories ;
 Affective symptoms:
 sadness, loss of gratification, apathy, loss of feelings and affection toward
others, loss of mirth response, anxiety.
 Motivational:
 wish to escape from life (usually via suicide); wish to avoid "problems" or
even usual everyday activities.
 Cognitive:
 difficulty in concentrating, problems in attention span, difficulties in
memory. The cognitive distortions— which are more on a conceptual or
information-processing level.
 Behavioral:
 passivity (e.g., lying in bed or sitting in a chair for hours on end),
withdrawal from other people, retardation, agitation.
 Physiological or vegetative:
 sleep disturbance (either increased or diminished sleeping); appetite
disturbance (either increased or decreased eating).

Translating "Chief Complaint" into
"Target Symptom"
 "I want to divorce my husband."
 Patient see all her relationships & interactions in absolutistic,
black-and-white terms.
 She could only see the negative features in her spouse—& in fact,
exaggerated these features.
 she interpreted the loss of feeling toward her husband as a sign
that her love for him was irreversibly lost.
 In fact, when not depressed, she had a happy, fulfilling
relationship with her husband.

 "I have no feeling."
 patients interpret lack of affective response as a sign that they
have undergone a permanent transformation. Patients do not
see these symptoms as aspects of depression but rather as signs
of some irreversible change in their personality.

Translating "Chief Complaint" into
"Target Symptom” (cont.)

 "I cannot handle my problems."
 patient greatly exaggerated some of her interpersonal difficulties & at
the same time underestimated her coping abilities.
 As a result of such negative evaluations of herself, her confidence eroded
further.
 a vicious cycle was established that progressively undermined her
capacity to master situations.

 "I am a terrible person."
 The patient interpreted symptoms of depression (such as slowing down,
difficulty in concentrating, loss of affection for her family) in the typical
negative, moralistic way seen among depressed patients.
 She viewed these symptoms as indicating that "I am lazy and self-
centered; I don't care about anybody but myself."

Feedback in the Initial Interview
(cont.)
 The feedback may be obtained in a number of
ways as follows:
1. The therapist summarizes the patient's
narrative or extracts the major problems. For
example, one-third of the way through an initial
interview, the therapist capsulizes the patient's
problem.
2. To make sure that the patient is really "tuned
in" to the therapist's summary of
conceptualizations, he should ask the patient
what he or she abstracts from the therapist's
statements.


 Of the utmost importance !
 Consists not only of the observation of the
patient's overt emotional responses during the
interview but also explicit statements by the
patient of his reaction to the therapist & the
therapy process itself.
 Reciprocal feedback is important in establishing
 (a) whether the therapist understands the patient's
problem &
 (b) whether the patient understands what the
therapist is saying.

(cont.)

The feedback may be obtained in a number of ways
as follows:
1. The therapist summarizes the patient's narrative
or extracts the major problems. For example, one-
third of the way through an initial interview, the
therapist capsulizes the patient's problem.

2. To make sure that the patient is really "tuned in" to
the therapist's summary of conceptualizations, he
should ask the patient what he or she abstracts from
the therapist's statements.

(cont.)
3. The third type of feedback has been alluded to
previously. The therapist tries to elicit covert reactions to
the interview that may be counterproductive. If there is any
sign of "static" in the interview, it is desirable for the
therapist to inquire as to what the patient is thinking.

4. Similarly, after proposing a homework assignment, the
therapist can say to the patient, "How do you feel about
this assignment? Do you feel that it is something that you
would like to tackle, or does it seem onerous to you. Or
would you prefer to think about it?“
By giving the patient a multiple choice, as it were, the
therapist is more likely to get a genuine response from the
patient.

(cont.)

5. Finally, it is important for the therapist to
get some feedback sometime during the first
part of a subsequent interview regarding the
patient's reactions to the previous interviews;
that is, reactions that had occurred following
the termination of the interview.

This would also be a good time to get the
patient's possible negative reactions to the
homework assignments.

 1. The therapist treating depressed patients requires a solid
background in psychopathology and diagnosis.

 2. Interview should be geared to establish:
 a. A therapeutic working relationship, including rapport
 b. Consensus on goals and treatment procedures
 c. Collaboration in defining and "solving" problems
 d. Appropriate interchange to provide optimum feedback to both
patient and therapist regarding reciprocal understanding,
stumbling blocks in therapy, progress toward goals, etc.

 3. The therapist should attempt to utilize technical
procedures to provide some symptom of relief in the first
session as well as in subsequent sessions. A mechanism for
maintaining symptom relief needs to be set up to utilize the
time between sessions optimally (for example, homework
assignments, listening to a tape recording of the previous
therapy session, etc.).

 4. The ideal way to motivate the patient to work on his problems
is to produce prompt lessening of symptoms through working
together on particular problems. Thus, "education" or
"reeducation" is preferable to prestige suggestion or
authoritarian reassurance.

 5. The therapist should work within the arbitrary time constraints
of the interview to achieve several concomitant technical goals:
 a. Establish a diagnostic profile
 b. Assess the degree of psychopathology
 c. Estimate the patient's assets for therapy and his social support system
 d. Obtain a solid data base in order to formulate the patient's problems.
This involves setting up and testing a hierarchy of hypotheses.
 e. Improvise and test out a variety of treatment strategies appropriate
for the particular stage of therapy.

 6. Utilizing time optimally may involve diplomatically
interrupting the patient when he rambles and guiding him back
to focusing on his problem.

Session 1 (BDI= 41)

Plan (Agenda) Assigned Homework
 Review symptoms of  Keep activity schedule: to
depression. ascertain how active the
patient is & to obtain
 Assess suicidal ideation & "objective" data about her
hopelessness. present level of functioning.
 Discuss influence of  Complete MMPI (to evaluate
degree of psychopathology
thinking on behavior with as well as obtaining research
specific reference to data).
depression.  Complete Life History
 Review activity level. Questionnaire to obtain
relevant past history.

Session 2 (BDI= 43)

 Review symptoms of  Continue with activity
depression. schedule with patient's
 Review activity schedule agreeing to attempt
checking for possible mastery &/or pleasure
omissions & distortions. activities.
 Begin to demonstrate  Define problems that
relationship between patient sees as
thinking, behavior & affect contributing to her
by using specific depression.
experiences of patient.

Session 3 (BDI=38)

 Review "Mastery &  Record cognitions during
Pleasure" activities. periods of sadness,
 Continue to elicit thoughts anxiety, & anger & during
related to sadness. periods of "apathy," in
order to elicit the
relationship between
thinking, behavior, &
affect.

Session 4 (BDI=31)

 Discuss specific cognitions  Continue recording
cognitions—if possible,
leading to unpleasant record alternative
affect. explanations; avoid labels
such as "incompetent" and
"selfish" since these
pejorative terms serve to
disguise problems.
 Rate on a scale of 0-10 the
degree to which she "wanted
to complete the activities" as
opposed to meeting the
therapist's or her husband's
expectations.

Session 5 (BDI=36)

 Discuss cognitions &  "Beds are for sleeping." If
identify recurrent or not asleep in 15 minutes,
common themes. get up & do something to
distract thinking.
 Continue to record
thoughts & list
responsibilities to husband
& vice versa.

Session 6 (BDI=29), session 7
(BDI=26), session 8 (BDI=26)
Plan Homework
 Review cognitions,  Continue to recognize
particularly her cognitive errors and review
expectations for herself & alternative explanations
her "shoulds" rather than for her negative
"wants." "automatic thoughts."
 Discuss her thoughts
regarding her marital
responsibilities.

(BDI =22), session 11 (BDI=30)
 Focus on self-criticisms & work on coping
 Plan  Homework
responses (that is, realistic evaluations of
problem areas rather than self-criticisms).
 Pursue responding to her "wants" rather than
her "shoulds." ;
 assertiveness discussions
 time management
 & future planning

Session 12 (BDI=15), session 13 (BDI=20),
session 14 (BDI=17), session 15 (BDI=17)

Plan Homework
 Continue to attend to self-  List "wants," particularly
criticisms with focus on future goals.
underlying assumptions.
 This assignment focus the
 Assess the basis for
patient on his own needs &
patient’s unrealistic self-
criticisms & other expectations.
depressive reactions.
 Investigate the patient's
attitudes & beliefs that
contributed to his
depression.

Session 16 (BDI=22), session 17 (BDI=18),
session 18 (BDI=12), session 19 (BDI= 14)

Plan Homework
 Review the similarities  Discuss goals with husband
between the patient’s in greater detail with
present reaction & past particular reference to
pattern of thinking. homemaking
responsibilities.
 These interchanges were
highly significant to help
the patient regain
motivation to pursue a
reasonable course of
action.

(BDI=6), session 22 (BDI=7)

 These final sessions attempt to consolidate
the gains made in therapy.

Follow Up: 1 month (BDI=9); 2
months (BDI=5); 6 months (BDI=2)
 During the follow-up period help the patient
remain non-depressed & note with
considerable pleasure being more confident.

 The patient "old automatic thoughts" would
still be elicited but he remains convinced that
the best approach to this ideation was a
careful reappraisal of the situation.

TECHNIQUES OF CBT
Focus on the details

BEHAVIORAL TECHNIQUES
Cognitive Change through Behavioral Change;
Behavioral techniques improve level of functioning,
counteract obsessive thinking, change dysfunctional
attitudes, & give a feeling of gratification.
By observing changes in his own behavior, the
patient may then be more amenable to examining
his negative self-concept.
An amelioration of the negative self-concept then
leads to more spontaneous motivation & an
improvement in mood.

Scheduling Activities
 A "graded task" hierarchy.

 Prescription of projects based on the clinical observation that depressed patients find
it difficult to undertake or complete jobs which they accomplished with relative ease
prior to the depressive episode.

 To counteract the patient's loss of motivation, inactivity, & his preoccupation with
depressive ideas.

 An hour-by-hour basis to maintain a certain momentum & prevent slipping back into
immobility.

 Focus on specific goal-oriented tasks to provide the patient & therapist with concrete
data on which to base realistic evaluations of the patient's functional capacity.

 The therapist should present the patient with a rationale “inactivity increases
negative ruminations & dysphoria”.

Mastery & Pleasure Techniques

Patients engage in activities but derive little
pleasure from them from either
(a) an attempt to engage in activities which
were not plesurable even prior to the
depressive episode,
(b) the dominance of negative cognitions which
override any potential sense of pleasure, or
(c) selective inattention to sensations of
pleasure.

Mastery & Pleasure Techniques
(cont.)
 Assign the task of undertaking a particular pleasurable
activity for a specified number of minutes each day &
request that the patient note changes in mood or reduction
of depressive ruminations associated with the activity.
 Make the patient record the degree of Mastery (M) &
Pleasure (P) associated with the activity.
 Mastery refers to a sense of accomplishment when
performing a specific task.
 Pleasure refers to pleasant feelings associated with the
activity.
 Mastery & Pleasure can be rated on a 5-point scale with 0
representing no mastery (pleasure) and 5 representing
maximum mastery (pleasure).

Mastery & Pleasure
 While severely depressed, a 38-year-old executive returned his
Activity Schedule with the following ratings of Mastery &
Pleasure on a 0-5 scale.

 Saturday MP
 8-9 a.m. Awoke, dressed, ate breakfast 1 1
 9-12 noon Wallpaper kitchen 0 0
 12-1 p.m. Lunch 0 0
 1-3 p.m. Watched TV 0 0

 The report indicates that although breakfast provided some
pleasure & just getting up was rated as achievement, the
remainder of the day provided no sense of pleasure or mastery.
Yet the patient did wallpaper a kitchen while very depressed.

Mastery & Pleasure
Clinical Application (cont.)
How did he discredit this apparent achievement?
Therapist: Why didn't you rate wallpapering the kitchen as a mastery experience?
Patient: Because the flowers didn't line up.
T: You did in fact complete the job?
P: Yes.
T: Your kitchen?
P: No. I helped a neighbor do his kitchen.
T: Did he do most of the work? (Note that the therapist inquires about any other
reasons for a sense of failure which might not be offered spontaneously.)
P: No. I really did almost all of it. He hadn't wallpapered before.
T: Did anything else go wrong? Did you spill the paste all over? Ruin a lot of
wallpaper? Leave a big mess?
P; No, no, the only problem was that the flowers did not line up.
T: So, since it was not perfect, you get no credit at all.
P: Well . . . yes.

Mastery & Pleasure
Clinical Application (cont.)
T: Just how far off was the alignment of the flowers?
P: (holds out fingers about Vb of an inch apart): About that much.
T: On each strip of paper?
P: No ... on two or three pieces.
T: Out of how many?
P: About 20-25.
T: Did anyone else notice it?
P: No. In fact, my neighbor thought it was great.
T: Did your wife see it?
P: Yeh, she admired the job.
T: Could you see the defect when you stood back and looked at the whole wall?
P: Well . . . not really.
T: So you've selectively attended to a real but very small flaw in your effort to wallpaper. Is it logical
that such a small defect should entirely cancel the credit you deserve?
P: Well, it wasn't as good as it should have been.
T: If your neighbor had done the same quality job in your kitchen, what would you say?
P: ... pretty good job!

Graded Task Assignment
(Goldfried, 1974)
key features of the Graded Task Assignment are:
1. Problem definition—for example, the patient's belief that he is not capable of
attaining goals that are important to him.
2. Formulation of a project. Stepwise assignment of tasks (or activities) from
simpler to more complex.
3. Immediate & direct observation by the patient that he is successful in reaching
a specific objective (carrying out an assigned task).
The continual concrete feedback provides the patient with new corrective
information regarding his functional capacity.
4. Ventilation of the patient's doubts, cynical reactions, & belittling of his
achievement.
5. Encouragement of realistic evaluation by the patient of his actual
performance.
6. Emphasis on the fact that the patient reached the goal as a result of his own
effort and skill.
7. Devising new, more complex assignments in collaboration with the patient.

Graded Task Assignment
Clinical example
 The therapist visited a 40-year-old woman patient on the first day of her
hospitalization. She was lying in her bed, ruminating about her problems and
"feeling miserable."
 The therapist was able to determine that in the past, she had enjoyed reading.
She stated, however, "I haven't even been able to read a headline in a newspaper
for the past couple of months."
 The therapist selected the shortest story in a collection from the library & urged
her to read it while he was with her. She said, "I know I won't be able to read it."
He replied, "Well, try reading the first paragraph out loud." She responded, "I
may be able to mouth the words but I won't be able to concentrate." He then
suggested, "See whether you can read the first sentence." She read the first
sentence aloud and continued until she had completed the paragraph. He asked
her to read some more but to try reading to herself. She gradually became
engrossed in the short story & spontaneously continued onto the next page. He
told her to keep reading and that he would return later.
 About an hour later, the therapist observed that her depression had indeed
lifted (temporarily). He encouraged her to undertake a regimen of reading
progressively longer short stories; by the end of the week, she was reading a
long novel. Within ten days after admission and with continued treatment, she
was well enough to return home.

Cognitive Rehearsal

 “asking the patient to imagine each successive step
in the sequence leading to the completion of the
task”.
 Forces the patient to pay attention to the essential details
of the activities & counteracts the tendency of his mind to
wander.
 patient has a preprogrammed system to carry out the
assignment.
 identify potential "roadblocks" (cognitive, behavioral, or
environmental) which might impede the achievement of
the assignment.
 Some patients report that they feel better simply as a result
of the completion of the assigned task in imagery.

Cognitive Rehearsal
Clinical example
The patient was a 24-year-old single unemployed female who after
some discussion agreed to attempt to attend her neglected exercise
classes.

 Therapist: So you agree that it would be a good idea to go to an exercise
class.
 Patient: Yes, I always feel good after them.
 T: Okay, well I'd like you to use your imagination and go through each
step involved in getting to the class.
 P: Well, I'll just have to go the way I've always gone.
 T: I think we need to be more specific. We know that you've decided to
go to class before but everytime you've run into some roadblocks. Let's
go over each step and see what might interfere with getting to class. I'd
like you to go through all the steps needed to get to your class. Go over
each step in your imagination and tell me what they are.
 P: Okay. I know what you mean.

Cognitive Rehearsal
Clinical example (cont.)
 T: The class starts at 9 a.m. What time should we start?
 P: About 7:30. I'll wake up to the alarm and probably be feeling lousy. I always hate starting the day.
 T: How can you handle that problem?
 P: Well, that's why I'll give myself extra time. I'll start by getting dressed and having breakfast. Then, I'll pick up my
equipment . . . (pause) . . . Oh, oh, wait, I don't have a pair of shorts to wear. That's one roadblock.
 T: What can you do to solve that problem?
 P: Well, I can go out and buy some.
 T: Can you visualize that? What comes next?
 P: I picture myself all ready to go and the car isn't there.
 T: What can you do about it?
 P: I'll ask my husband to bring the car early.
 T: What do you picture next?
 P: I'm driving to the class and I decide to turn round and go back.
 T: Why?
 P: Because I think I'll look foolish.
 T: What's the answer to that?
 P: Well, actually, the other people are just interested in the exercise, not in how anybody looks.

Assertive Training & Role-Playing

 Training of specific skills using techniques as
modeling, coaching, & behavior rehearsal.
 Role-playing involves the adoption of a role
by the therapist, the patient, or both, and the
subsequent social interaction based on the
assigned role.
 the therapist attempts to clarify self-
defeating or interfering cognitions.

Rationale & Timing of BT

Depressed patients are prone to distort the
purpose of the tasks post facto. It is the
therapist's responsibility to insure that the
patient interprets the results of an
assignment within the confines of the initial
objective. The initial objective, therefore,
must be made clear from the beginning.

Rationale & Timing (cont.)

 To evaluate the patient's understanding of a task
is to use a role-reversal.
 The utilization of a "significant other" (spouse,
other relative, or close friend) is often very
helpful in setting & implementing behavioral
assignments.
 Appropriate targets of behavioral techniques
include passivity, avoidance, lack of gratification,
& an inability to express appropriate emotions
(such as anger and sadness).


 Homework assignments also need to be graded to
the patient's level of understanding. In general,
homework is not assigned until the patient
completes a form of the assignment in the session.
 Telephone conversations between patient and
therapist;
 the agreement to call the therapist when the patient is
"stuck" in carrying out an assignment is very helpful.
 This practice enables the patient to identify and master his
problems in the "real life situation" and also motivates him
to continue with his assignments.
 "Reporting in" to the therapist by telephone when the
patient has completed a series of assignments also
provides a powerful motivation to carry out the projects.


 Once the patient understands the rationale and
application of the behavioral techniques, therapy
proceeds to more "purely" cognitive approaches.
If behavioral symptoms or problems reappear,
the patient may need a "refresher course" or may
simply reinstitute the behavioral techniques.
 In times of stress, many former patients return
to activity scheduling or recording.
 Since the techniques have already been
mastered, they are easily used to prevent
incipient regression.

COGNITIVE TECHNIQUES
Be aware of the fact that many depressed patients are so
preoccupied with negative thoughts that further introspection
may aggravate the perseverating ideation.

The Influence of Cognitions on
Affect & Behavior
 to demonstrate the relationship between
thinking and affect use the "induced imagery"
technique;
 The therapist first asks the patient to imagine an
unpleasant scene. If the patient indicates a negative
emotional response, the therapist can inquire about
the content of the patient's thoughts. The therapist
then asks the patient to imagine a pleasant scene and
to describe his feelings. Typically, a patient is able to
recognize that by changing the content of his thought
he is able to alter his feeling state.

Cognition & Recent Experiences

 Demonstrate to the patient the presence of
cognitions in his sphere of awareness.

 it is essential for the patients to become
aware of & to identify their negative
cognitions.

Detection of Automatic Thoughts

 Assign a specific project designed to delineate
the patient’s dysfunctional cognitions;
 the patient is instructed to "catch" as many cognitions
as he can and to record them in writing. the patient
can use changes in affect or the experience of
dysphoria as a marker or cue to recognize or recall his
cognitions.
 Direct the patient to set aside a specific brief
period of time, for example, 15 minutes each
evening, to replay the events that led to his
cognitions.

Recording Dysfunctional Thoughts

 Recording cognitions and responses in parallel columns
 to begin examining, evaluating, and modifying the cognitions.
 The patient writes his cognitions in one column and then write a
"reasonable response" to the cognitions in the next column.
 The written assignment may also include additional columns for
describing the patient's affect and behavior, and the specific
description of the situation or event which preceded the
cognition.
 depending on the number of columns used, the technique may
be referred to as the double-column, the triple-column, or even
the quadruple-column technique. “The Daily Record of
Dysfunctional Thoughts “
 rationale for this approach is to teach the patient more precise
discriminations of his emotions & to think of reasonable
responses to his negative cognitions.

Recording Dysfunctional Thoughts
Clinical example

Examining & Reality Testing Automatic
Thoughts & Images

 Not to induce a spurious optimism by inducing him
to think that "things are really better than they are,"
but to encourage a more accurate description &
analysis of the way things are.
 Therapist should not fall into a trap of assuming that
all of the patient's pessimistic or nihilistic statements
are necessarily invalid;
 examine a sample of the patient's thoughts in collaboration
with the patient.
 The basis or evidence for each thought should be subjected
to the scrutiny of reality testing with the application of the
kind of reasonable standards used by nondepressed people
in making judgments.

Examining & Reality Testing Automatic Thoughts &
Images
Clinical example
For example, a depressed young student expressed the belief that she
would not get into one of the colleges to which she had applied. When
the therapist explored the reasons which led to her conclusion, he
discovered there was little basis for it.

T: Why do you think you won't be able to get into the university of your
choice?
P: Because my grades were really not so hot.
T: Well, what was your grade average?
P: Well, pretty good up until the last semester in high school.
T: What was your grade average in general?
P: A's and B's.
T: Well, how many of each?
P: Well, I guess, almost all of my grades were A's but I got terrible grades my
last semester.

Examining & Reality Testing Automatic Thoughts &
Images
 T: What were your grades then?
 P: I got two A's and two B's.
 T: Since your grade average would seem to me to
come out to almost all A's, why do you think you
won't be able to get into the university?
 T: Because of competition being so tough.
 T: Have you found out what the average grades are
for admissions to the college?
 P: Well, somebody told me that a B+ average would
suffice.
 T: Isn't your average better than that?
 P: I guess so.

Reattribution Techniques

 Depressed patients are particularly prone to self-
blame resulting from the negative consequences
of events beyond their control as well as those
relative to their actions and judgments.
 Used when the patient unrealistically attributes
adverse occurrences to a personal deficiency,
such as a lack of ability or effort.
 Not to absolve the patient of all responsibility
but to define the multitude of extraneous factors
contributing to an adverse experience.

Reattribution Technique
Clinical example
The patient was a 51-year-old moderately
depressed bank manager who complained
primarily of "ineffectiveness in my job." By
"ineffectiveness" the patient referred to a
difficulty he experienced in making business
decisions.

Reattribution Technique
 P: I can't tell you how much of a mess I've made of things. I've made
another major error of judgment which should cost me my job.
 T: Tell me what the error in judgment was.
 P: I approved a loan which fell through completely. I made a very poor
decision.
 T: Can you recall the specifics about the decision?
 P: Yes, I remember that it looked good on paper, good collateral, good
credit rating, but I should have known there was going to be a problem.
 T: Did you have all the pertinent information at the time of your
decision?
 P: Not at the time, but I sure found out 6 weeks later. I'm paid to make
profitable decisions, not to give the bank's money away.
 T: I understand your position, but I would like to review the information
which you had at the time your decision was required, not 6 weeks after
the decision had been made.

The Search for Alternative Solutions

 The depressed patient's closed system of
logic & reasoning opens as he distances
himself from his cognitions and identifies the
rigid patterns & themes of his thinking.
 At this point, the "search for alternatives"
may prove useful.
 involves the active investigation of other
interpretations or solutions of the patient's
problems. This approach forms the
cornerstone of effective problem-solving.

Counteracting Automatic Thoughts

Use of the Wrist Counter
 After the patient correctly identifies faulty cognitions &
distinguishes them from "normal," adaptive, or neutral
thoughts.
 the therapist check regularly to insure that the patient is
"checking" the kinds of cognitions of importance to the
therapy “negative cognitions “:
 (1) They are automatic—they occur as if by reflex, without prior
reasoning;
 (2) they are unreasonable & dysfunctional;
 (3) they seem completely plausible & are uncritically accepted as
valid even though they seem bizarre upon reflection;
 (4)they are involuntary. The patient may have great difficulty in
"turning them off."
 Each patient has his own idiosyncratic kind of automatic
thoughts.

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