My client Charlie had a stressful situation with the doorman at his friends’ apartment building. He was asked to sign in, which he did not want to do and hadn’t had to do in the past, and assumed the doorman was wielding his power.
The following blog was written by a research assistant who had been exposed to CBT in her job. She had recently attended the Depression and Suicidality workshop at the Beck Institute.
Depressed clients often isolate themselves from others and withdraw from life. A depressed client of mine I’ll call Adam did exactly this. He began feeling depressed after his marriage ended. He stopped responding to calls and social invitations from friends and family members. He also stopped going to the gym and gave up his favorite hobby, golfing. When clients withdraw from life, they give up any chance of meaningful or pleasurable experiences, so their depression is more likely to continue and become more intense.
To counter the isolation and withdrawal common to depression, therapists can introduce behavioral activation. This strategy entails getting clients more active and involved in life by scheduling activities that have the potential to improve their mood. Research suggests that behavioral activation alone is an evidence-based treatment for depression, and may be particularly well-suited for chronically depressed clients (Sturmey, 2009). The following tip from the Beck Institute therapists can help make behavioral activation even more effective.
It’s important to focus on valued or meaningful activities instead of, or in addition to pleasurable activities as part of behavioral activation. Many depressed clients (especially those with chronic or severe depression) state that there aren’t any activities that give them a sense of pleasure. They may also come to the following session feeling frustrated and hopeless because they didn’t enjoy the activities as much as they had before they became depressed, or they didn’t enjoy them at all. While emotions and moods are temporary, values tend to be more stable and can serve as a guide for behavioral activation. We can obtain the client’s values by listing different value categories and then asking the client to rate the strength of each category from 0 (not valuing it at all) to 10 (the most they can value something). The categories we include are work, self-education/learning, volunteering, intimacy, family, friendship, religion/spirituality, entertainment/recreation, and health/fitness. Adam’s most valued categories were friendship (10), family (9), recreation/entertainment (8), and health/fitness (8).
The client’s value ratings indicate the best place to begin with behavioral activation. Start with the highest value rating, which, for Adam, was friendship. We ask our clients, “Why is [the value] important to you?” Adam responded that friendship was important to him because it provided mutual support and shared experiences. We then ask the client to list specific, concrete activities that make up the value category. For friendship, Adam’s list of activities included: poker night, golfing, watching sports together, going out to dinner, and regular phone calls. We then repeat these steps for the remaining high value categories. Typically, we won’t ask about a category if the client rated it below a 5 out of 10.
Finally, we help the client decide which valued activities to engage in. Instead of telling the client what to do, we collaboratively ask the client which activities they want to schedule. In his friendship category, Adam decided to call his friend, Matt, to inform him that he would be attending their weekly poker night on Wednesday. During poker night, Adam decided to seek support from his friends by talking about having a difficult time after his divorce and making additional plans for the weekend with whoever was available. He agreed to suggest they play a round of golf on Sunday.
Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33, 818-829.
Learn more about treating depression at the CBT for Depression and Suicide workshop.
Aaron T. Beck and Keith Bredemeier – Department of Psychiatry, University of Pennsylvania
We propose that depression can be viewed as an adaptation to conserve energy after the perceived loss of an investment in a vital resource such as a relationship, group identity, or personal asset. Tendencies to process information negatively and experience strong biological reactions to stress (resulting from genes, trauma, or both) can lead to depressogenic beliefs about the self, world, and future. These tendencies are mediated by alterations in brain areas/networks involved in cognition and emotion regulation. Depressogenic beliefs predispose individuals to make cognitive appraisals that amplify perceptions of loss, typically in response to stressors that impact available resources. Clinical features of severe depression (e.g., anhedonia, anergia) result from these appraisals and biological reactions that they trigger (e.g., autonomic, immune, neurochemical). These symptoms were presumably adaptive in our evolutionary history, but are maladaptive in contemporary times. Thus, severe depression can be considered an anachronistic manifestation of an evolutionarily based “program.”
Background: Major depressive disorder (MDD) causes a massive disease burden worldwide. Cognitive behavioural therapy (CBT) is an important treatment approach for depression. Cost-utility analysis (CUA) is a method to support decisions on efficient allocation of resources in health policy. The objective of our study was to systematically review CUA of CBT in the treatment of patients suffering from MDD.
Methods: We conducted a systematic literature search in Medline, Embase, PsycINFO and National Health Service Economic Evaluation Database (NHS EED) to identify CUA of CBT for MDD. Cost data were inflated to the year 2011 and converted into USD using purchasing power parities (USD PPP) to ensure comparability of the data. Quality assessment of CUA was performed.
Results: Twenty-two studies were included in this systematic review. No study employed a time horizon of more than 5 years. In most studies, individual and group CBT as well as CBT for maintenance showed acceptable incremental cost-utility ratios (<50,000 USD PPP/quality-adjusted life year). The CUA results of CBT for children and adolescents and of computerized CBT were inconsistent.
Discussion: We found consistent evidence that individualized CBT is cost-effective from the perspective of a third-party payer for short-term treatment and for relapse prevention of MDD in the adult population.
Brettschneider C., Djadran H., Härter M., Löwe B., Riedel-Heller S., & König H.H. (January 2015). Cost-utility analyses of cognitive-behavioral therapy of depression: A systematic review. Psychotherapy and Psychosomatics (84), 1, 6-21.
Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.
To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.
Design, Setting, and Participants
A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.
The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.
Main Outcomes and Measures
The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.
Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program’s overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program’s benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program’s effect on depression-free days.
Conclusions and Relevance
The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.
Brent, D. A., Brunwasser, S. M., Hollon, S. D., Weersing, V. R., Clarke, G. N., Dickerson, J. F., Beardslee, W. R., … Garber, J. (January 01, 2015). Effect of a cognitive-cehavioral prevention program on depression 6 years after implementation among at-risk adolescents: A randomized clinical trial. Jama Psychiatry, 72, 11, 1110-8.
Clinical Psychologist at Beck Institute
Mindfulness-based interventions have been becoming more popular in psychotherapy. One such treatment, Mindfulness-Based Cognitive Therapy (MBCT), has specifically been developed to prevent relapse in clients who have experienced recurrent major depressive episodes (Segal, Williams, & Teasdale, 2001). We have incorporated mindfulness strategies into our work at the Beck Institute. Instead of thinking about mindfulness-based interventions as separate treatments, however, we think about mindfulness as a potential strategy to use in a larger CBT framework. I’ll review one common mindfulness technique we use with our non-suicidal depressed clients.
A body of research has demonstrated rumination to be an important factor in maintaining depression (e.g., Nolen-Hoeksema, 2000). We view rumination as a strategy clients use to cope with depression. For example, Mark, a client I recently treated, felt depressed, then ruminated to try to figure out why he felt depressed. His ruminative thoughts included, “Why do I feel so depressed? What’s wrong with me? I just can’t do anything right, like I got a bad review at work. My friends don’t try to call me either. . .” I worked with this client to help him identify his beliefs about the rumination process instead of solely evaluating the content of each thought.
First I help clients identify, and then evaluate, beliefs about rumination. I start this way (instead of going straight into mindfulness) because clients tend to continue to use strategies that they view as helpful. I want them to recognize that rumination is doing them more harm than good. One way to identify beliefs about rumination is to complete a cost-benefit analysis, eliciting from clients the advantages and disadvantages of rumination. Instead of using the term “rumination,” I asked them what they call the strategy (e.g., “asking myself why,” “listing all of my problems,” “trying to think my way out of depression”).
Typical advantages include “It helps me figure out my problems;” “I can come up with solutions.” “I’ll be able to know what to do next time I feel depressed.” Next we list the disadvantages, such as: “It makes me feel worse.” “Once I start, it’s hard to stop.” Then we evaluate each advantage. For instance, I asked Mark, “How often do you come up with a specific solution?” and “If ruminating helped you solve your problems, do you think they would be solved by now?” Next we evaluate whether the advantages or disadvantages are stronger. Clients have effectively assessed their positive beliefs about rumination when they conclude that the disadvantages outweigh the advantages. A list of the advantages and disadvantages shows clients the consequences of rumination and acts a motivator to stop the unhelpful strategy. (If the advantages are still stronger, you’ll need to either spend more time evaluating the advantages or add to the disadvantages.)
The next step is to teach clients how to use mindfulness as a strategy to disengage from rumination. I record the mindfulness exercises (usually using clients’ cell phones) to make it easier for them to practice. Before I start, I guide clients through a rumination induction by having them close their eyes and actively think about a topic involved in their typical ruminations. I get them to simulate the process of ruminating in session so they can experience being able to disengage from the rumination process. As I noted before, this strategy should not be used with actively suicidal clients because it can increase their depressed mood and sense of hopelessness.
Once clients have been ruminating for about 30 seconds, I ask for a rating of their depressed mood from 0-10, turn on the recording app on their phone (“voice memos” on iPhones or “voice recorder” on Androids), and begin guiding them through a mindfulness of the breath exercise that lasts for 5 minutes. At 5 minutes, I get another mood rating, end the exercise, and ask them about the experience (e.g., “What did you notice?” “Were you able to let go of ruminative thoughts and refocus on breathing?” “What happened to your mood over time?”) The vast majority of clients learn that it’s possible to disengage from rumination, and that by not actively ruminating, their mood gradually improves. I make sure to emphasize that mindfulness is not for the purpose of making them feel better or suppressing thoughts but is a strategy to help them relate to their thoughts in a different manner. Their action plan then consists of listening to the recording every day (preferably at the beginning of the day to serve as a reminder to use mindfulness throughout the day) and to use mindfulness by letting go of thoughts and refocusing on the breath with their eyes open whenever they notice themselves ruminating during the day.
Dr. Hindman will be teaching mindfulness exercises as part of the CBT for Depression – Core 1 workshop at Beck Institute in March and the CBT for Anxiety workshop in Chicago in April.
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504-511.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). Mindfulness-Based Cognitive Therapy for depression. New York: Guilford Press.
Beck Institute for Cognitive Behavior Therapy is a leading international source for training, therapy, and resources in CBT.
Soldiers Suicide Prevention (Beck Institute) is a Combined Federal Campaign (CFC) Approved Charity: CFC # 11590
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