Cognitive Behavioral Therapy for Depression– an introduction

1. Cognitive Behavioral Therapy for Depression– an introduction Dr Kate Hardy, Clin.Psych.D Post Doctoral Fellow Prodromal Assessment, Research and Treatment Team (PART), UCSF Kate.Hardy@ucsf.edu

2. Objectives • 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

3. What is depression? • 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

4. What is depression - continued • 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/complete-publication.shtml)

5. Evidence base • 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’

6. Core beliefs Underlying assumption Critical incident Activate assumptions Thoughts Feelings Behaviour Physical Cognitive Model of Depression Early Experiences

7. 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

8. Five areas of CBT Environment Thoughts Biology behavior Mood

9. Core beliefs Underlying assumption Critical incident Activate assumptions Thoughts Feelings Behaviour Physical Maintaining Factors Early Experiences

10. First sessions • Socialize to the model • Previous experience of therapy and expectations • Contracting • Assessment • Problem list • Goal setting • Agenda setting

11. Goal Setting • Specific • Measurable • Achievable • Realistic • Time limited

12. Be goal SMART • I want more friends • I want to stop worrying • To stop thinking negatively about everything

13. What if the client can’t think of a goal? • Magic/miracle question (solution focused therapy) • 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

14. Scaling questions • 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

15. Eliciting Negative Automatic Thoughts (Hot thoughts) • 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)

16. Downward Arrow Technique • 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

17. Downward arrow 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

18. Case study – Diana • 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

19. Background • 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

20. Current situation • 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

21. Problem list • 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

22. SMART Goals for Diana • 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

23. Early experiences • 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

24. 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 Behavior Keep quiet Leave the room Avoid people at work Physical Nauseous Heart racing Formulation for Diana Early Experiences Observe physical violence

25. Interventions • Behavioral activation • Monitor activities through a daily diary • Rate each activity out of 10 for pleasure and mastery (sense of achievement) • Rate level of depression • Schedule activities based on information from the diary

26. Interventions continued • Thought challenging • Use thoughts identified on thought record and rate how much believe the thought • List all evidence that supports the thought • List all evidence that suggests the thought is not true 100% of the time • Based on the evidence re –rate how much you believe the original thought, an alternative thought and re-rate emotion

27. Interventions continued • Behavioral experiments • 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

28. Interventions used with Diana • 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) • Survey • Asked children how they knew she loved them and how does she know they love her

29. Interventions used continued • 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 • Relaxation

30. Sue – case study • 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

31. Sue – core beliefs and assumptions • Core Beliefs • I need the help of others • I am not good enough • Other people will always let me down • 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

32. Possible interventions • In pairs think about what interventions could be developed with Sue

33. Interventions used • 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

34. Recommended Reading • 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. • 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#GroupCognitiveBehavioralTherapyofMajorDepression