Implementing treatment

1. Implementing treatment Individual Treatments for Major Depressive Disorder

2. The IB Syllabus Says: • Examine biomedical, individual and group approaches to treatment. • Evaluate the use of biomedical, individual and group approaches to the treatment of one disorder. • Discuss the use of eclectic approaches to treatment. • Discuss the relationship between etiology and therapeutic approach in relation to one disorder.

3. Two individual treatments: • Cognitive Therapy/CBT • Psychodynamic Therapy

4. Individual Approaches to the treatment of depression:Cognitive Therapy/CBT Cognitive therapy/ CBT Etiology & treatment: • One of the symptoms of depression is distorted cognitions (e.g. negative self-defeating thoughts). • This has lead cognitive psychologists to suggest that replacing negative cognitions with more realistic and positive one can help the depressed person. • This clearly demonstrates the connection between the cognitive etiology and treatment.

5. Beck’s (1963) Cognitive Therapy Outline of Beck’s (1963) Cognitive Therapy • Aaron Beck is a pioneer in Cognitive Therapy. He developed his theory on the early 1960s based on the idea of Cognitive Restructuring and his theory is still at the core of many cognitive therapies (e.g. CBT). • The key principles of this approach are to: • Indentify negative, self-critical thoughts that occur automatically • Note the connection between negative thought and depression • Examine each negative thought and decide whether it can be supported • Replace distorted negative thoughts with realistic interpretations of each situation • According to Beck, a persons beliefs contribute to “automatic thoughts” based on schemas. In depression, negative self-schemas bias a persons thinking. • Beck saw negative thoughts as the reason behind depression and developed the cognitive triad. He found that depressed people tend to draw illogical conclusions when they evaluate themselves, negative thoughts lead to negative feelings that can result in depression. – Beck called this the cognitive triad.

6. Beck’s ‘cognitive triad’ that leads to depression (Beck, 1963)

7. Cognitive Behavioral Therapy (CBT) http://www.youtube.com/watch?NR=1&v=GVX4iVXtT-o&feature=endscreen http://www.youtube.com/watch?v=JSO6iAFekPw http://www.youtube.com/watch?NR=1&v=fCZpUIEUsys&feature=endscreen Background: • CBT is a brief form of psychotherapy used for the treatment of adults and children with depression. In contrast to traditional forms of psychotherapy (such as psychodynamic therapy) which are concerned with a persons past history, CBT focuses on current issues and symptoms. The Aims of CBT: • Help the client to change faulty thinking patters and underlying schemas • Help the client to develop coping strategies and problem solving skills, and to engage in behavioral activation The CBT Procedure: • Typically, there are around 12-20 weekly sessions, combined with daily practice exercises specifically designed to help the client to use new skills on a day-to-day bases. CBT is based on Cognitive therapy (Beck, 1963) and also includes behavior modification.

8. Cognitive Behavioral Therapy (CBT) The Theory Behind CBT (theoretical framework): • The first aim of CBT is to identify and correct faulty cognitions and unhealthy behaviors. • The client is encouraged to find out what thoughts are associated with depressed feeling, and to correct them – this is called cognitive restructuring. This is based on the assumption that peoples interpretations and inferences about the things that happen to them affect their thinking and behavior. • These cognitive processes may become distorted, but since they are accessible to consciousness, the individual has the powerto change them. • For example, people suffering from depression can be seen as focusing to much on their failures. The therapist will try to re-focus the clients attention on what he or she's does well and to take note of daily successes.

9. Cognitive Behavioral Therapy (CBT) Beck’s Six Patterns of Faulty Thinking: • Beck argues that there are six patterns of faulty thinking which lead to mental disorders such as depression. • Arbitrary inference: Drawing wrong conclusions about oneself by making invalid connections – e.g. when it rains on the day that you have organized a picnic, you think that only you have bad luck and the world is against you. • Selective Abstraction: Drawing wrong conclusions by focusing a single part of a whole – for example, focusing on a single bad grade and ignoring the fact that you actually have an A in the class.

10. Cognitive Behavioral Therapy (CBT) Beck’s Six Patterns of Faulty Thinking: • Overgeneralization: Applying a single incident to all similar incidents – for example, just because you have a relationship problem with a friend means that you are unsuccessful in relationships and have no true friends. • Exaggeration: Overestimating the significance of negative events – for example, shortness of breath whilst exercising is seen as a sign of major illness and imminent death. • Personalization: Assuming that others behavior is done with the intention of hurting and humiliating you – for example, when someone does not greet you when he or she passes by, you assume that person is angry with you or hates you. • Dichotomous Thinking: An all or nothing approach to viewing the world – e.g. ‘you either love me or you hate me’.

11. Cognitive Behavioral Therapy (CBT) The relationship between Distorted Thinking and Schemas • Research has found that people with psychological problems are often prone to negative automatic thoughts which they cannot control. – for example “ I never do anything right” • Underlying the cognitive distortions is a cognitive schema, which processes incoming information so that it fits with biased self-perception – for example, positive events or successes may be filtered out to fit in with the view of the self as a failure.

12. Cognitive Behavioral Therapy (CBT) Behavioral Activation: • The second aim of CBT is to encourage people to increase gradually in any activities that could be rewarding, such as sport, going to a concert, or meeting other people. This is the behavioral activation component of CBT. • A problem in depression is that depressed people typically stop doing things that may potentially be enjoyable because they think it is not worth doing them. • The CBT therapist can also help the client to find new ways to deal with what seem to be big problems, by braking them down into small steps.

13. Cognitive Behavioral Therapy (CBT) The teaching of “Meta –Awareness”: • According to Teasdale (1997) the important feature in CBT may be to reach the clients ‘meta – awareness’ – that is the ability to think about their own thoughts. • Thoughts and feelings are seen as mental events that can be examined objectively and changed if necessary. • Teasdale (1997) states that the overall aim of the therapy is to teach clients to monitor thought processes and then to test them against reality, so that they can eventually change their behavior.

14. Evaluation: Strengths Evaluation: CBT • Just as effective as drug treatments: Elkin et al. (1989) carried out one of the best controlled outcome studies, conducted by the National Institute of Mental Health (NIMH) in the US to examine the effectiveness of drug treatments in comparison to other types of therapy. They found CBT to be just as effective as drug therapies. Furthermore, Hallon et al. (1992) found antidepressants to equally effective and than drug treatments. CBT has also been found be very effective for mild cases of depression. • Better than Placebos or No Treatment: Dobson (1989) carried out a clinical trial and found cognitive therapy to be superior to no treatment or to a placebo. • CBT combined with drugs the best treatment: Nemeroff et al. (2003) found that CBT in combination with drugs was the most effective for chronic depression in people who had suffered from traumatic childhood experiences. This group was helped with either therapy alone or a combination of therapy and drugs, rather than with drugs alone. However, more research is needed to come to more reliable and valid conclusions. • Structure & Goals: Well structured, with clear goals and measurable outcomes. It is also empowering for the client because they learn new skills and ways to cope. • Less chance of Relapse:Hallon et al, (1992) Lower relapse rates are evident in depressed individuals who have CBT treatment than drug treatments. • Cost Effective: CBT is cost effective because it does not usually involve prolonged treatment(12-20 weekly sessions). • No Side Effects: CBT does not have the side effects that drug treatments have. No negative effects have been found. • A Model for Living: The cognitive approach offers a ‘model for living’ that promotes wellness and avoids the stigma of mental illness associated with biomedical therapies. It empowers people.

15. Evaluation: Strengths Evaluation: CBT • The effectiveness of CBT & SSRIs with teenagers Aim: Riggs et al. (2007) aimed to study the effectiveness of CBT in combination with either a placebo or an SSRI Procedures: This study was a randomized double blind study with 126 adolescents (from the USA), aged 13-19, who suffered from depression as well as a substance use disorder and a conduct disorder. Many of the participants were recruited from the social service and juvenile justice systems. The researchers wanted to include adolescents with substance misuse as well as depression because this group are at risk on many levels and not much research focuses on them. Clinicians are often less willing to prescribe antidepressants to them because they think that the adolescents should first and foremost stop abusing drugs. Findings: • The researchers found that the adolescents in the study complied with treatment to a large extent. • It was not possible to follow up six of the participants, two withdrew consent and 12 could not complete the study because their were either in jail or relocated. • After the study participants were rated by a clinician who what that 67% of the patients in the CBT + Placebo group and 76% of the SSRI drug + CBT group were judged as “very much improved” after being treated for four months. Conclusions: • The researchers concluded that treatment with drugs and CBT is the most effective but that treatment with a placebo and CBT is almost as effective. • The participants self report after the study showed that depression had decreased and so had other behavioral problems. • The researchers argued that teaching the adolescences cognitive and behavioral techniques helped them to manage their negative thoughts and feelings that could trigger substance abuse. • They also say that it is important to treat adolescent depression, especially if a person suffers from another psychological disorder as well. Treatment could start with CBT alone, and if the patient does not respond to that, a drug from the SSRI group should be added.

16. Evaluation: Weaknesses Evaluation: CBT • Individual Differences: in order for CBT to be successful clients need to keep applying the techniques and skills acquired in therapy. There are individual differences in participants ability to carry on performing the techniques taught in therapy. • Self Sufficiency: The cognitive model has also been criticised because it suggests that everyone should be self-sufficient. The Cognitive therapist Ellis (1963) had little sympathy for those suffering with depression, regarding it as an ‘indulgence’ in self-defeating thought. This draws attention away from the need to improve social conditions that have a significant effect on the quality of life. • Focusing on Symptoms rather than the cause: CBT has been criticized for focusing on symptoms rather than the cause of major depressive disorder. Beck (1991) himself has pointed out that, although cognitive processes are involved in many psychological disorders, they may be a consequence rather than a cause of the problems. • Ethical considerations: it has been argued that providing clients with strategies to self help, is not as manipulative as other treatments, but some ethical issues may arise as it is the therapist who is making judgments concerning which thoughts are acceptable. CBT also ignores the possibility that some of the so called irrational thoughts may be true and therefore rational. • Not an in depth-discussion: The therapy program is short, and it is it is not so helpful for clients who want to discuss their conflicts in depth (such as in psychodynamic therapy) • Cultural issues: the therapist must be very sensitive to the clients linguistic and cultural background for CBT to be effective. • Is it really Cost effective?:even though more cost effective than other individual therapies (such as psychodynamic therapy which takes longer) the cost of treatment does go up when individual rather than group therapy is followed.

17. Individual Approaches to the treatment of depression:Psychodynamic Therapy The theory behind psychodynamic therapy: • Sigmund Freud (1915) was an influential psychodynamic psychologist. Using evidence gained from his case studies of people suffering from mental disorders, Freud was convinced that mental disorders occur because of unresolved -- usually unconscious -- conflicts, often originating from childhood. • The goal of this type of therapy is for the patient to understand and better cope with these feelings by talking about the experiences which led to them (catharsis).

18. Conscious The small amount of mental activity we know about (current thinking processes) Preconscious Things we could be aware of if we paid attention to them Unconscious Things we are unaware of and plays a major role in our behavior Freud’s levels of consciousness pain Painful childhood memories are repressed to the unconscious mind (this is a defense mechanism)

19. Psychodynamic Therapy The relationship between etiology and treatment: • The Freudian psychoanalytic view relates depression in adulthood to the individuals early relationship with parents. Hostile feelings towards parents, its is claimed are redirected towards the form of self-accusation and self-hatred. • The Psychodynamic views sees the repression of early trauma re-emerging in adulthood in the form of depression. • In his theory of ‘attachment & separation’ Bowlby (1973) proposes that separation or loss of the mother during early childhood could result in severe depression in adulthood.

20. Psychodynamic Therapy How psychodynamic therapy works: • Freud (1915) developed a method called psychoanalysis – often called the ‘talking cure’. From this, many other psychotherapies have evolved. • These therapies seek to uncover unconscious psychodynamic processes in order to facilitate insight into the conflicts and anxieties that are the underlying causes of mental disorders. • Understanding what happened in the past can help people to better deal with situations that are happening in a persons life now (catharsis). • According to psychodynamic theory, the unconscious is revealed in dreams – ‘the royal road to the unconscious’,therefore, one of the techniques of psychoanalyse is dream analysis. • Free association is also used where clients are encouraged to let their thoughts wonder and say whatever comes to their heads – the idea is that these thoughts will reveal what the underlying conflicts are, and the analyst can then interpret a clients behaviour based on what they say.

21. Evaluation of Psychodynamic Therapy • Cost & efficiency: Eysenck (1967) proposed that the treatment is costly, time consuming and ineffective. • Relevance: Critics have suggested that the theory is culture bound and has little relevance in our modern times. • Deterministic: This model is deterministic because individuals have very little conscious involvement in their own personality development. • Finding a cause: Radwan (2010) proposes that if the depression was a result of unresolved unconscious conflicts then Psychodynamic therapy may be very helpful in dealing with it. By gaining an understanding of the underplaying conflicts that caused clients are able to come up with practical solutions that can resolve these conflicts. • Better than CBT in the long term: Taylor (2008) proposes that even though CBT may act quicker, psychodynamic therapy may be more beneficial in the long term.

22. Individual treatments: Questions to check your knowledge and understanding: • What is the relationship between the etiology and treatment through Cognitive Therapy/CBT? • Give an outline of Beck’s (1963) Cognitive Therapy • What are the Key Principles of Cognitive Therapy? • What is the role of schema processing in Cognitive therapy? • Give an explanation of Beck’s Cognitive Triad • Explain the Background Cognitive Behavioral Therapy (CBT) • What are the Aims of CBT? • What is the CBT Procedure? • What is the theoretical framework behind CBT? • What is behavioral activation? • What is the teaching of ‘Meta–Awareness’? • What are Beck’s 6 patterns of faulty thinking? • Make an evaluate point about CBT being ‘Just as effective as drug treatments’. • Make an evaluate point about CBT being ‘Better than Placebos or No Treatment’. • Make an evaluate point about ‘CBT combined with drugs the best treatment’ for CBT. • Make an evaluate point about ‘Structure & Goals’ in CBT. • Make an evaluate point about ‘Less chance of Relapse’ with CBT. • Make an evaluate point about CBT being ‘Cost Effective’. • Make an evaluate point about ‘No Side Effects’ in CBT. • Make an evaluate point about CBT as ‘A Model for Living’. • Outline the aims procedures, findings and conclusions of Rigg’s (2007) study of the effectiveness of CBT & SSRIs with teenagers study. What are Beck’s 6 patterns of faulty thinking?

23. Make an evaluative point about ‘Individual Differences:’ in relation to CBT. • Make an evaluative point about ‘Self Sufficiency in CBT’. • Make an evaluative point about CBT ‘Focusing on Symptoms rather than the cause’. • Make an evaluative point about ‘Ethical considerations’ in CBT. • Make an evaluative point about CBT as ‘Not an in depth-discussion’. • Make an evaluative point about ‘ Cultural issues’ in CBT • Make an evaluative point about whether CBT is really ‘Cost effective’. • What is the relationship between the etiology and treatment through Psychodynamic Therapy • Outline the theory behind psychodynamic therapy. • Give an Explanation of Freud’s Levels of Consciousness. • Explain how psychodynamic therapy works. • Explain how Psychodynamic therapy is the ‘Talking Cure’: • Explain ‘Dream Analysis’ in Psychodynamic therapy • Explain ‘Free Association’ in CBT. • Make an evaluative point about ‘Cost & efficiency’ of psychodynamic therapy. • Make an evaluative point about the ‘Relevance’. • Make an evaluative point about the ‘Deterministic’ nature of therapy. • Make an evaluative point about ‘Finding a cause and psychodynamic therapy. • Make an evaluative point about psychodynamic therapy being ‘Better than CBT in the long term’.