Cognitive Therapy for Depression Monica Ramirez Basco Ph

Cognitive Therapy for Depression Monica Ramirez Basco, Ph. D. Clinical Psychologist Clinical Associate Professor The University of Texas Southwestern Medical Center at Dallas

Background and Overview

Overview of Depression

Types of Depression Unipolar Major Depression n Bipolar Depression n Dysthymic Disorder n Chronic Depression n Atypical Depression n Depression due to medical conditions n Depression due to substance abuse n

Major Depression n Mood - sad, dysphoric, irritable, anxious mood n Cognitions - negative outlook and attitude n Physical symptoms – sleep, appetite, energy n Behavior – procrastination, inactivity,

Bipolar Depression n Looks like Major Depression n At least one manic episode in lifetime n Antidepressant medications can cause mania n Mood stabilizing medications are indicated

Dysthymic Disorder n Less severe than major depression n Usually chronic, early onset n Double depression n When major depression remits, dysthymia often continues

Chronic Depression n Major Depression that is long lasting n Minimum of two years duration n Difficult to treat n Characterological problems are present n Depression is familiar and

Atypical Depression n Reactive Mood n Reverse vegetative symptoms n Rejection sensitivity n Confused for a personality disorder

Depression due to Medical Conditions n Thyroid dysfunction n Cancer n Poorly controlled Diabetes n Chemotherapy n Endocrine problems

Depression due to Substance Abuse n Alcohol abuse and dependence n Drug abuse – e. g. , cocaine use n Depression started when drug and alcohol use started n When sober, symptoms are less severe n Which came first? Self-medication?

Introduction to Patients n Depression changes the way you Think n Act n Feel n

When people are depressed they… n n Think negatively about n Themselves n their future n other people n the world in general Their negative thoughts are often distorted

When people are depressed they… n Jump to conclusions n Blow things out of proportion n Ignore positive aspects of their lives n Focus on the negative n Think in extremes

When people are depressed they… n Act in counter-productive ways. n Cope poorly with their problems n Procrastinate n Avoid people n Self-medicate shopping with alcohol, drugs, food,

When people are depressed they… n Feel sad, blue, hopeless, empty n Feel irritable, angry, frustrated n Feel anxious, fearful, tense, nervous n Are easily overwhelmed n Experience a mix of emotions

Goals of Cognitive Therapy a. Correct cognitive distortions. b. Reduce emotional distress. b. Cope with problems effectively.

What is Cognitive. Therapy?

Cognitive. Therapy is… A short-term skills oriented therapy n In each session you will learn new coping skills n Correct negative thinking n Control emotions n Cope better with problems n Take control of your life n

Cognitive Therapy Set goals the patient wants to achieve n Keep track of progress toward those goals n Make a plan at the beginning of each session for how time should be used n Learn new skills n Practice skills between sessions n

Structure All therapy sessions have structure n Update of patient’s status n Discussion of problems n Solutions planned n Closure n Plan to meet again n

Structure of CBT n Brief update and Mood check n Review previous session n Set the Agenda n Review homework

Structure of CBT n n Discuss the issues on the agenda Teach skills Create homework along the way Summarize and feedback

What CT can do and what it cannot do

How it differs and is similar to otherapeutic models

Why choose CT for your patient population

How CT is learned

Good CT begins with good therapy

Basic Principles of Cognitive-Behavior Therapy

The Cognitive Model EVENT Thoughts Feelings Actions

The Cognitive Model EVENT Thoughts Faulty Information Processing Feelings Actions Faulty Coping Strategies Emotions Gutlevel Instincts Physical Symptoms

The Cognitive Model of Depression Thoughts Self-criticism Hopelessness Feelings Actions Inactivity Poor coping Sadness Anxiety Irritability

The Cognitive Model of OCD Thoughts Obsession Worry Feelings Actions Ritual or Avoidance Fear Anxiety

The Cognitive Model of Social Phobia Thoughts Mind-Reading Catastrophizing Feelings Actions Avoidance Fear Embarrassment

The Cognitive Model EVENT Thoughts Feelings Actions

Automatic Thoughts n Occur rapidly in response to a situation n Are not subjected to systematic, logical analysis n A person may be unaware of their presence or significance

Faulty Information Processing n Distortion of available information n Guessing at missing information n Ignoring available information n Categorical or absolutistic thinking

Cognitive Errors minimization

Cognitive Errors Catastrophizing Jumping to Conclusions Mind Reading Emotional Reasoning

Cognitive Errors Disqualifying the Positive Mental Filter

Absolutes and White Right or Wrong Black Shoulds or Shouldn’ts All or nothing

EVENT Thoughts Faulty Information Processing Actions Feelings

Schemas n Rules n Attitudes n Core Beliefs n Identity, values, and meaning n May be positive or negative n May be adaptive or maladaptive

Factors that Influence Schema Development n Parental teaching or modeling n Trauma n Culture n Societal norms n Learning experiences n Mental illness

The Cognitive Model Thoughts Feelings Actions

Capturing Automatic Thoughts n How to capture automatic thoughts n Verbal thoughts vs. imagery n Thought diaries: uses, formats, and exercise

Focus on one Automatic Thought n Pick a thought that helps you demonstrate the intervention n Ask the patient to choose thought from the thought record that is the most upsetting n Select the thought associated with the most intense emotions

Hot Cognitions

Logical Analysis of Automatic Thoughts Generate evidence that supports the automatic thought n Generate evidence against the automatic thought such as n Events n Experiences n Input from others n What your logic tells you n

Review the Evidence Have the person read aloud the evidence in both columns n Ask what they think about the evidence listed n Remind them that it is not about which column has the most items. It is about which evidence is the most convincing. n Ask how strongly they still believe the original negative automatic thought n

Drawing a Conclusion n Did the intensity of belief in the negative automatic thought change? n Did the emotion associated with the thought change? n In which direction? n What piece of evidence was most convincing?

Conclusions n If the automatic thought is false: Change it n If the automatic thought is true: Problem Solving n If the conclusion is unclear: Set up an experiment to test the thought Go to

Coping Cards Reminders of conclusions n Reminder of procedure n Affirming statements n Troubleshooting n

Conducting Experiments Determine what is to be tested n Find opportunities for testing thoughts n Make a plan n Test predictions n Reevaluate automatic thought n Draw conclusions n

Generating Alternative Explanations n What else could explain the person’s experience? n What is another way of looking at the situation? n If you were not so depressed, what might you say about the situation?

Gaining Distance n What would someone else say in this same situation? A friend? A family member? n What would you say to a friend who was in this same situation? n Could this alternative view apply to you?

Tic Toc n TIC: Task Interfering Cognitions Thoughts that get in the way of progress. n Discouraging thoughts n Thoughts that arouse more emotion n n TOC: Task Orienting Cognitions Thoughts that motivate n Thoughts that encourage action n Thoughts that reduce emotions n

Socratic Questioning In response to negative automatic thoughts: n Help me understand why you feel this way. n Tell me more about that thought. n What makes you think that? n Are you certain about that? n How do you figure? n Where did you get that idea?

End of Day 1

Recap from previous day n n Q and A Thought records homework Coping Cards Hot Cognitions

Thought Stopping for Obsessive and Intrusive Thoughts n Recognition n Breathing n Stop image n Switch imagery n Repeat if needed

Coping with hopelessness and suicidality n Reasons to Live n Reasons to Have Hope n Distraction n Behavioral Plan n Finding Meaning in Life

Decatastrophizing Anxious Thoughts n Recognition n Probability of occurrence n Evaluate the evidence n Efforts to reduce risk n Ways to cope

Thoughts about trauma n Cognitive Triad n Evaluating Meaning n Issues of Prevention n Coping

Advantages and Disadvantages n Advantages of Change n Disadvantages of Change n Advantages of not Changing n Disadvantages of not Changing n Patterns n Decreasing – and Increasing +

Advantages and Disadvantages Decision making n Overcoming depression n

Schema Work

Advantages and Disadvantages n Advantages of keeping schema n Disadvantages of keeping schema n Advantages of changing schema n Disadvantages of changing schema

Getting the Big Picture n Historical Analysis of Evidence n That was then, this is now n How I have changed n How I have not changed n Circumstances

Momma said… Considering the possibility that parents were wrong n Messages received reflected parents’ issues n Context – under what circumstances? n Do they still apply? n

More Socratic Questions Tell me about that n What makes you think that? n How to you understand that? n Where did you get that idea? n Is that really true? n Do you really believe that? n What do others say? n

End of Day 2

Recap from previous day n n n Q and A Schemas about doing Cognitive Therapy Review of Intervention grid

The Cognitive Model Thoughts Feelings Actions

Behavioral Activation When setting goals for treatment select one behavior or activity that can be easily accomplished n What action would you like to see yourself take during the next week? n If you accomplish this how would it make you feel about yourself? n Specify how, when, and where the action will take place. Troubleshoot. n

Mastery and Pleasure n Activity Monitoring n Measure M and P (0 -7 scale) n Prescribe increased M and P n Assess outcome

Graded Task Assignment n Identify a large task n Break into smaller subtasks n Assign one step at a time n Add positive reinforcement for completion

A list and B list n Limits activities n A list: 1 -2 items that are urgent n B list: 1 -2 items that would like to get to n Finish A list items before starting B n Plan ahead

Compliance model n Everyone is capable of compliance n Obstacles can interfere n Identify the obstacle and remove or prevent it

Obstacles to Compliance n Intrapersonal n Interpersonal n Social System n Treatment n Cognitions

Problem-solving to increase compliance How can the obstacle be reduced? n What can you do once the obstacle occurs? n Generate ideas n Pick one or two n Test their effectiveness n Modify the plan n

Homework Compliance Picture when and where you would do your homework n How will you remember to do it? n Where will you keep your materials? n What could keep you from doing your homework? n How can those obstacles be avoided? n

UCS (trauma) lead to UCR (fear) Rape causes pain and fear

UCS becomes associated with CS Perpetrator was a man Rape associated with all men Men are the new CS

CS elicits CR (fear) All men elicit fear

Goal of Treatment is to “unpair” the CS and the CR Not all men cause fear

Reciprocal Inhibition You cannot feel relaxed and fearful at the same time

Reciprocal Inhibition Teach Relaxation Exercise n Teach methods to control negative thoughts n Teach decatastrophizing methods n Create a hierarchy n Start with the easiest item and work through the hierarchy n Systematic exposure with relaxation response and cognitive methods n

Negative Reinforcement Behaviors that stop a noxious stimulus n Avoidance n Giving in n Giving up n Distracting through internet, TV n

Avoidance in Depression Negative Reinforcement Paradigm ________________ Stress about completing a task Avoidance Anxiety Reduced

CBT Model of OCD Negative Reinforcement Paradigm ________________ Ritual Anxiety Reduced & Obsession Stops

Avoidance Response in PTSD Negative Reinforcement Paradigm ________________ Avoidance Anxiety Reduced

Social Phobia Self-Criticism reinforces low-confidence Avoidance

Punishment Anything that makes the behavior less likely to occur n Humiliation in social situations n Stress when trying to do a task n Feeling overwhelmed n Panic attacks in stressful situations n Flashback and nightmares in PTSD n

Operant Learning in Substance Abuse Stimulus (Alcohol) elicits Response (euphoria, decreased anxiety) n Response is positively reinforcing n Avoidance of Pain with Alcohol is negatively reinforcing n Change reinforcement contingency n Add alternate S to get the R n

Breaking the Cycle in Depression Stress about completing a task Avoidance Anxiety Reduced

Breaking the Cycle in Depression Stress about completing a task Take Action Anxiety Reduced

Breaking the Cycle in OCD Negative Reinforcement Paradigm ________________ Ritual Anxiety Reduced & Obsession Stops

Breaking the Cycle of Anxiety ________________ in OCD Relaxation Response & Thought Stopping Anxiety Reduced & Obsession Stops

Breaking the Cycle in PTSD ________________ Avoidance Anxiety Reduced

Breaking the Connection ________________ Exposure + Coping Anxiety Reduced

Graded Exposure Develop a hierarchy n Arrange least to most difficult n Develop relaxation method n Develop cognitive restructuring n Assign first item n Get feedback n

Coping Behaviors Identify faulty coping actions n Examine their advantages and disadvantages n Develop new coping behaviors n Practice n Evaluate the outcome n Positive reinforcement for better coping n

Rumination Make a list of things to do, to worry about, problems, events n Relax n Cross off the list anything that you cannot do anything about, cannot control n Cross off things that are not urgent n Make a plan for tomorrow n

The Cognitive Model Thoughts Feelings Actions

Factors that Influence Emotions Temperament n Role Models n Learning Experiences n Mental Illness n Pain and other general health problems n

Relaxation Training Controlled Breathing n Focused Breathing Technique n Progressive Muscle Relaxation n Imagery n

End of Day 3

Recap from previous day n n Q and A Procrastination and other roadblocks to achieving goals

Protocol for Depression a. Setting the Agenda b. Assessment and Rapport Building c. Setting Goals for treatment d. Skills Training e. Problem-Solving

Structure of First Session a. Establishing Rapport b. Socializing patient to cognitive therapy c. Education about Depression

Structure of First Session (continued) d. Eliciting patients’ thoughts about therapy 1. Prior experiences with therapy 2. How they would like this to be different e. Patient History f. Begin to develop a goal list

Structure of additional sessions a. Brief update and Mood check b. Elicit thoughts about the previous session c. Set the Agenda d. Review homework

Structure of additional sessions (continued) e. Discuss the issues on the agenda 1. Current problem from goal list 2. Mood shifts since last visit 3. Anticipated stressful events 4. Create homework along the way 5. Summarize each item before going to the next.