VA Training in Evidence-Based Psychotherapies: Cognitive Behavior Therapy for Depression

1. VA Training in Evidence-Based Psychotherapies: Cognitive Behavior Therapy for Depression Gregory K. Brown, Ph.D. VISN 4 MIRECC, Philadelphia VAMC Bradley Karlin, Ph.D. Office of Mental Health Services, VA Central Office VA Psychology Training Council EBP Workgroup

2. Background • In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001) • The VA developed a Mental Health Strategic Plan in response to the President’s New Freedom Commission on Mental Health report (2004) • The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country

3. Goals of VA Training in EBPs • To train VA staff from multiple disciplines in evidence-based psychotherapies • To augment psychotherapies already being offered in VA medical centers

4. VA Dissemination and Training in EBPs • Cognitive Behavioral Therapy (CBT) for Depression • Acceptance and Commitment Therapy (ACT) for Depression • Cognitive Processing Therapy (CPT) for PTSD • Prolonged Exposure (PE) for PTSD • Social Skills Training (SST) for severe mental illness (SMI) • Integrative Behavioral Couple Therapy (IBCT) • Family Psychoeducation (FPE) • Behavioral Family Therapy (BFT) • Multi-Family Group Therapy (MFGT)

5. EBP Presentations for Interns and Postdoctoral Fellows • VA EBP rollout training has been focused on staff • VA Psychology Training Council (VAPTC) developed a workgroup in 2009 to focus on developing EBP training for interns and postdoctoral fellows

6. Goals of these EBP Presentations • To provide a basic working knowledge of each of the rollout EBPs • To provide the foundation for trainees to seek out further training and supervision in the EBPs they intend to implement

7. Limitations • This presentation will not provide equivalent training to the EBP rollouts • This presentation will not provide the skills to implement the treatment without further training and supervision

8. What is Cognitive Behavioral Therapy? Cognitive Behavioral Therapy (CBT) is a structured, short-term, present-oriented psychotherapy directed toward modifying dysfunctional thinking and behavior and solving current problems. 7

9. Why provide CBT training? • Cognitive Behavioral Therapy (CBT) most extensively tested psychosocial treatments for depression (DeRubeis & Crits-Christoph, 1998) • CBT found to be strongly correlated with an individuals’ changed cognitions and their improved depression (DeRubeis, Evans, Hollon, Garvey, Grove, & Tuason, 1990; DeRubeis, & Feeley, 1990, Oei & Free, 1995; Oei & Sullivan, 1999)

10. Overview of CBT • CBT is based on Lewinsohn’s behavioral model and Beck’s cognitive model for treating depression. • CBT consists of 45-minute, individual psychotherapy sessions. • CBT is a short-term therapy consisting of 12-16 weekly or biweekly sessions.

11. General CBT Paradigm Situation AutomaticThoughts Behavior Emotion 10

12. Cognitive Model

13. “ABC” Model How thoughts influence mood (and behaviors): A  B C Activating Belief/ Consequence Event Thought 12

14. Cognitive Model • Situation (or activating event) may not always be an external event. • Situation can be a an internal event: memory, thought, emotion, or sensation that may prompt an automatic thought.

15. Automatic Thoughts They are quick, evaluative thoughts or images that are situation specific. They are the most superficial level of cognition, closest to conscious awareness. Patients may not be aware of the thoughts impact on mood. 14

16. Cognitive Model: Jack Situation Lost job and currently unemployed Automatic Thoughts “The world has screwed me over. Everyone I know makes my life difficult. I’m better off without them.” Reaction Anger 15

17. Cognitive Model: Kate Situation Lost job and currently unemployed Automatic Thoughts “My life means nothing now. I’m a horrible person.” Reaction Depressed 16

18. Negative Cognitive Triad SELF “I am inadequate.” “I’m unlovable.” Depression WORLD FUTURE “The world is cruel.” “Things will never get better.”

19. Levels of Cognitive Processing Core Belief I’m incompetent. Situation Listening to lecture Automatic Thought “This is too hard. I’ll never understand this.” Reaction Sad, Drops Out of Program 18

20. Core Beliefs (Schemas) Most central, fundamental beliefs about ourselves, others, and our world Absolute and rigid beliefs (+ or -) Usually developed in childhood Become active during external life events Core Beliefs represent content (meaning) Schemas also include cognitive processes: Biases in attention, storage, and access of information.

21. Levels of Cognitive Processing Core Belief “I’m useless.” Intermediate Beliefs “If I’m unable to work, then I’m useless.” Compensatory Strategies Focus solely on work-related achievements 20

22. Intermediate Beliefs Conditional Rules or Statements (+ or -) “If people don’t admire me, then I am a failure.” “If I don’t complete this task perfectly, then I am incompetent.” “If I work very hard, then my hard work will pay off.” 21

23. Compensatory Strategies 1. Maintaining Strategies that support the core belief Vulnerable Belief Aggression 2. Opposing Strategies that prove the core belief is wrong Inadequate Belief Overachieve 3. Avoiding Strategies that do not activate the core belief Unlovable Belief Avoid Intimacy

24. Core Beliefs Intermediate Beliefs Compensatory Strategies Situation Automatic Thoughts Reaction: Emotional, Behavioral, Physiological

25. CBT Case Conceptualization Critical family members Undiagnosed learning disability Problems in school EARLY EXPERIENCES “I'm no good.” “I’m incompetent.” CORE BELIEFS “If something doesn’t work out, I’m a failure.” “If I don’t try anything new, I won’t get disappointed.” INTERMEDIATEBELIEFS COMPENSATORY STRATEGIES Avoid challenging situations. Drug use 24

26. Behavioral Model

27. Lewinsohn’s Behavioral Model Two behavioral patterns associated with depression: Low rate of response-contingent positive reinforcement, especially from others High rate of punishment Depressed individuals do not get enough positive reinforcement from interactions with their environment to maintain adaptive behavior. 26

28. Lewinsohn’s Depressive Cycle Lack of active engagement in one’s environment Depressive symptoms 27

29. Breaking the Cycle Behavioral Strategies Increase the frequency of positive experiences. Break patterns of avoidance and hopelessness. Decrease the frequency of aversive occurrences, if possible. If not possible, problem-solving approaches can be used. Relationship between cognitions and behavior is a “two-way street.” Wright, Basco, & Thase, 2006, p. 21 29

30. Integration of Cognitive and Behavioral Models Activated Beliefs “I’m a loser. Nothing I do works out.” Situation: Negative Life Event Divorce Behavioral Response Staying home from work, avoiding social interaction Emotional Reaction Sad, hopeless 30

31. BEHAVIORAL STRATEGIES OF CBT

32. Behavioral Activation Behavioral Activation is a simple technique for engaging the patient in a process of change and that stimulates positive movement and hope. Therapist helps the patient to choose one or two actions that could make a difference in how he or she feels and then assists with working out a plan to carry out the activity (Wright, Basco & Thase, 2006). 32

33. Behavioral Activation Use Socratic questioning to educate patient about behavioral model of depression: Role of positive/negative reinforcement Effect of depression on engagement in pleasant activities Assess the impact of pleasant activity engagement on mood: Ask “How do you think this change could make you feel?” 33

34. Behavioral Activation Collaboratively, choose assignments that are manageable. Match the patient’s energy level and capacity for change. Be sure that it offers some challenge without overloading the patient. Small steps often lead to bigger strides!

35. Activity Monitoring Process for identifying patient’s baseline engagement in pleasant activities. Depressed patients under-engage and under-report positive experiences and focus more on failures than successes. Write down activities no matter how mundane using Activity Monitoring Form. Evaluate: Pleasure (P): 0-10 scale Mastery/Accomplishment (M): 0-10 scale Rate overall mood for day 35

36. Activity Monitoring Form 36

37. Reviewing the Activity Monitoring Form Review the form with patient collaboratively. Use questions to guide the process. Goals: Help patient recognize link between behaviors/activities and mood. Begin to recognize pleasant and unpleasant behaviors or thematic areas to expand upon in activity scheduling process (next step). Questions: “Were there periods of time when you experienced pleasure?” “What kinds of activities gave you pleasure?” Are pleasure/mastery ratings higher when spending time with others, or in other thematic areas? Review overall mood ratings in relation to activities (or lack thereof): Ask, “Tell me about your mood on each day.”

38. Activity Scheduling:Scheduling Pleasant Activities Develop structured Activity Schedule for engaging in pleasant activities over next week Be concrete Keep it simple and achievable for specific patient Relaxing and rewarding activities can have a positive effect on co-occurring anxiety that may contribute to depression 38

39. Activity Schedule 39

40. Identifying Pleasant Activities Brainstorm new rewarding and meaningfulactivities: “What pleasurable activities did you used to do in the past that have been stopped or reduced?” Incorporate information learned from Activity Monitoring Form. Administer Pleasant Events Schedule (MacPhillamy & Lewinsohn, 1982) or similar pleasant events inventory. Don’t overlook simple yet pleasant activities: Pleasant gestures, self-care, self-promoting activities

41. Activity Scheduling: Final Step Assess motivation/ambivalence, and problem solve, as appropriate “How do you feel about doing this over the next week?” “How likely is it that you will do this?” “What do you think might stand in your way of following the schedule?”

42. COGNITIVE STRATEGIES OF CBT

43. Identifying Automatic Thoughts Notice a shift or increased affect. Have the patient describe a problematic situation or time when there was an affect shift. Have the patient use imagery to describe an event in detail. Basic Question to Ask During the Session: “What was going through your mind just then?” 43

44. Identifying Automatic Thoughts What do you guess you were thinking about? Do you think you could have been thinking about _____ or ______ ? Were you imagining something that might happen or remembering something that did? What did this situation mean to you? Were you thinking _____? (Therapist chooses thought that is opposite of the expected thought) 44

45. When Should Thought Records Be Introduced? Patient is able to identify emotions (Feelings Handout). Patient understands the “A-B-C” Model. Patient endorses the value of identifying and evaluating thoughts. Therapist should verbally evaluate an automatic thought that results in a change in mood before introducing the thought record. 45

46. Introducing Thought Records Present the Thought Record as a “test” to see if thoughts and emotions are really linked. Talk about this as an experiment to see if changing thinking does in fact change feelings & subsequent behavior. Some patients like to think of themselves as “detectives” or “scientists.” 46

47. Thought Records Use a whiteboard, blackboard, easel or a simple piece of paper. Provide a notebook or binder to write down to record and evaluate their thoughts. If the patient is reluctant to write down their thoughts and evaluations of the thoughts [or has limited educational, language or English speaking skills] write it for them sitting in a side-by-side position. 47

48. Thought Records Have patient select a specific, concrete situation associated with shift or escalation of affect. Patient must agree that the thought is a high priority problem and/or feels very upset/distressed. Finally, identify the sequence of what happened that led up to the negative emotions, thoughts, feelings and responses. 48

49. Thought Records Ask the patient to describe the event in great detail. Ask detailed questions or use imagery so that the patient experiences negative emotions during the session. Ask: “What was going through your mind just then?” or “What were you thinking?” 49

50. Stage 1: 3-Column Thought Record Use 3-Column Thought Record: “Date,” “Event,” “Automatic Thoughts,” and “Emotions.” Write down the date and name of the situation. Write down the emotion and rate the intensity of the emotion (0-100). Write down the automatic thought. Do not attempt to evaluate thoughts with low intensity ratings (< 50-60). 50