CBT as long as Depression: An Introduction Debbie Spain Tutor Dept. of Mental Health
Holliday, Anne, Lifestyles Editor has reference to this Academic Journal, PHwiki organized this Journal CBT as long as Depression: An Introduction Debbie Spain Tutor Dept. of Mental Health Florence Nightingale School of Nursing & Midwifery Learning outcomes By the end of the session, you will be able to: Define depression Outline behavioural in addition to cognitive models of depression Discuss the application of key CBT principles in addition to strategies Begin to critique the evidence-base Low mood: a continuum of experience Is it normal to feel sad Are there any differences between sadness, grief in addition to depression When does normal sadness become depression (Horwitz in addition to Wakefield, 2007)
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Depression: diagnostic criteria (WHO, 1992) Core symptoms: Low mood Pervasive loss of interest or pleasure (anhedonia) Significant weight change Sleep disturbance Observable agitation or retardation Loss of energy Feeling worthless or unnecessarily guilty Poor concentration or attention Recurrent thoughts of death or suicide Pattern must be present as long as most of the day as long as at least two weeks Causing impairment in addition to some interference to daily functioning Depression: key stats Incidence: Depressive episode = 4 – 10% of adults Dysthymia = 2.5 – 5% of adults (NICE, 2010) By 2020, depression will be the second cause of global disability in addition to burden (WHO, 2010) High rates of physical in addition to mental health co-morbidities Depression: key stats Positive associations found between depression in addition to the following (e.g. Gilbert, 2000; NICE, 2010): – Gender – Socio-economic status – Social factors – Adverse life experiences – Physical illness
Depression: aetiology (NICE, 2010) Contributory factors as long as depression may include: – Neuro-biological factors – Genetic predisposition – Physical illness – Stress vulnerability / social factors – Psychological models – Behavioural model – Cognitive model CBT: key principles Man is not affected by events but by the views he takes of them (Epictetus) Links between thoughts, feelings in addition to behaviour Emphasis on the here in addition to now Important to establish current maintaining factors Depression: aims of CBT assessment Obtain in as long as mation about current symptoms in addition to impact Develop a shared underst in addition to ing (a as long as mulation) Provide psycho-education about CBT Normalise experiences Start to develop a therapeutic relationship Instil hope Risk assessment Identification of clinically appropriate intervention/s (e.g. Mulhern, 2010; Townend in addition to Grant, 2010)
Depression: CBT assessment Questions to consider: Are there any symptoms of depression that might impact on undertaking an assessment Why might it be important to normalise experiences Why might it be important to instil hope What factors might render psychological interventions unsuitable as long as someone who is depressed How can we improve the process of assessment CBT models as long as depression Behavioural model Behavioural Activation Cognitive model cognitive therapy Cognitive-behavioural models cognitive in addition to behavioural techniques Behavioural model: background Based on learning theory: – Classical conditioning Pavlov – stimulant induces a response – Operant conditioning Skinner behaviour induces a response (Tyrer in addition to Steinberg, 2008) Symptoms in addition to behaviour are the disorder
Classical in addition to operant conditioning How do behaviours maintain in addition to perpetuate low mood Developing a as long as mulation Behavioural model: Theories of depression Loss of response-contingent positive rein as long as cement (Skinner, 1953) Stimulus e.g. work, social occasions, telephone calls absence of positive low mood, no interest, consequences or reward no energy, no motivation Response inactivity, procrastination, isolation
BA: a theoretical framework BA: Formulation Functional analysis TRAP: – Triggering events – Responses – Avoidance Patterns TRAC: – Triggering events – Responses – Alternative Coping BA: treatment rationale BA aims to re-establish the sense of achievement in addition to enjoyment out of everyday life by: Increasing the amount, range, in addition to difficulty of activities Balancing different types of activities Taking the time necessary as long as task completion
BA: overview of treatment Activity monitoring Activity rating (MASTERY & PLEASURE) Activity scheduling Activity grading Activity monitoring / scheduling Activity rating Rate each activity using a scale 0-8; 0 meaning not at all in addition to 8 meaning very much Put a P with the rating next to activities that may give pleasure in addition to enjoyment (e.g. watching TV, eating) Put an M with the rating next to activities that may give a sense of achievement (doing the housework, taking kids to school)
Activity scheduling Use a diary to plan hour-by-hour activities Schedule in tasks so as to increase the activity levels Schedule in tasks which the person has to do in balance with tasks that the person wants to do, so as to maximise mastery & pleasure Activity grading Graded task assignment Four potential outcomes: 1. Omit, if the tasks exceed the available time 2. Delegate, wherever possible 3. Seek help in addition to support whenever possible 4. Grade the task BA: the evidence base Cuijpers, P. et al. (2007). Behavioural activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27, 318 326. Mazzucchelli, T. et al. (2009). Behavioural Activation Treatments as long as Depression in Adults: A Meta-analysis in addition to Review. Clinical Psychology: Science in addition to Practice, 16(4), 383-411.
Cognitive model: background Thinking in addition to cognition shape our view of the world The ABC model (Ellis, 1962): Activating event Beliefs about activating event Consequence (emotional or behavioural) of belief (Tyrer in addition to Steinberg, 2008) Cognitive model: A Beckian as long as mulation (Beck 1976) Early Experience Core Beliefs About self/others/world Conditional statements If then Situations or events where rules are broken or assumptions activated Cognitive model: key aspects Thoughts in addition to thinking style likely contribute to the development in addition to maintenance of depression Depression exaggerates processes inherent in all of us: a continuum of functioning Depression affects the way we view ourselves, the world in addition to other people (Mulhern, 2010)
Cognitions: contributing to development in addition to persistence of depression Content: themes of loss, self devaluation, hopelessness Process: – bias towards the negative – reduced flexibility – cognitive style Interpretation bias: – negative events are explained by internal factors – positive events are explained by external factors not attributed to self Bias results in an absence of positive experience past in addition to present Common thinking styles Jumping to conclusions Predicting the future All or nothing thinking Emotional reasoning Discounting the positive Catastrophising Dwelling on the negative Egocentric thinking Rumination Reduced meta-cognitive awareness (Gilbert, 2000) Cognitive therapy: planning treatment Treatment plan is in as long as med by conceptualisation Structured in addition to time limited Focus upon maintaining factors Collaborative, not confrontational Reliant upon guided discovery not didactic Socratic questioning is key Educational – promoting self application of CBT skills
Some considerations CBT as long as depression typically involves changing unhelpful / avoidance behaviours, in addition to examining unhelpful thoughts in addition to patterns of thinking Increasing evidence as long as several modes of CBT delivery Therapy outcomes are determined by several key factors including a shared as long as mulation, consideration of non-specific variables, in addition to ongoing assessment of risk in addition to need Proactive strategies are as important as reactive strategies References Cuijpers, P. et al. (2007). Behavioural activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27, 318-326. Gilbert, P. (2000). Overcoming Depression. (2nd ed). London: Constable & Robinson. Horwitz, A. in addition to Wakefield, J. (2007). The Loss of Sadness. Ox as long as d: Ox as long as d University Press. Keedwell, P. (2008). How sadness survived. The evolutionary basis of depression. Ox as long as d: Radcliffe Publishing. Kuyken, W in addition to Dimitrios, T. (2009). Therapist competence, Comorbidity in addition to Cognitive-Behavioural Therapy as long as Depression. Psychotherapy in addition to Psychosomatics, 78(1), 42-48. Mazzucchelli, T. et al. (2009). Behavioural Activation Treatments as long as Depression in Adults: A Meta-analysis in addition to Review. Clinical Psychology: Science in addition to Practice, 16(4), 383-411. References Mulhern, R. (2010). Depression. In A Grant, M Townend, R Mulhern in addition to N Short (2010). Cognitive Behavioural Therapy in Mental Health Care. London: SAGE. Neff, K. www.self-compassion.org NICE. (2010). CG90 Depression. London. HM Publications. Richards et al (2012) Computer-based psychological treatments as long as depression: A systematic review in addition to meta-analysis. Clinical Psychology Review. 32, 4, 329-342. Townend, M. in addition to Grant, A. (2010). Fundamentals. In A Grant, M Townend, R Mulhern in addition to N Short (2010). Cognitive Behavioural Therapy in Mental Health Care. London: SAGE. Tyrer, P. in addition to Steinberg, D. (2008). Models as long as Mental Disorder: Conceptual Models in Psychiatry. (4th ed). Chichester: John Wiley & Sons. WHO. (1992) ICD-10. WHO.
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