Cognitive-Behavioral Therapy for Depression

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					Cognitive-Behavioral Therapy
           for Depression

PSYC 4500: Introduction to Clinical Psychology
             Brett Deacon, Ph.D.
             November 22, 2011

• Please complete course evaluations!
• Current response rate: 10/36
               Remaining Schedule
• Tuesday 11/22: Cognitive-behavioral therapies for

• Thursday 11/24: NO CLASS (Thanksgiving break)
• Tuesday 11/29: Eye movement desensitization and

• Thursday 12/1: Prescription privileges for psychologists
• Final exam: Thursday 12/8 at 10:15
     Very Important Announcement

• I have decided NOT to require you to write
  response papers for the last two readings
• I will give all of you full credit for these papers
• You still need to read the articles, ponder the
  questions I’ve posted, and come prepared to
  discuss the articles
    Questions for Herbert et al. (2000) article, for
    Tuesday 11/29 (NO RESPONSE PAPER DUE)
•     1. Why do think EMDR has become so popular
      among therapists?
•     2. What can be concluded about EMDR from the
      observation that component studies generally find
      that imagery without eye movements is as effective
      as standard EMDR?
•     3. Which one of the FiLCHeRS (essential features of
      science) do you find most troublesome about
    Questions for Fox et al. (2000) article, for
  Thursday 12/1 (NO RESPONSE PAPER DUE)
• 1. Do you think that organized medicine’s historical (and current) opposition to
  prescription privileges for non-physicians like nurse practitioners, optometrists,
  and psychologists reflects (a) concerns about a public health hazard, (b)
  concerns about other professions encroaching on their turf, or (c) both?
• 2. The American Psychological Association (APA) requires practicing clinical
  psychologists to pay an extra $137 per year in membership fees, which it calls
  a “Practice Assessment.” According to APA’s website, “this fee supports APA’s
  companion organization, the APA Practice Organization which is exclusively
  devoted to advancing the goals of the practitioner community.” A major goal of
  the APA Practice Organization is to advocate prescription privileges for
  psychologists, and much of the revenue raised by the $137 Practice
  Assessment supports this effort. What do you think of APA’s policy of charging
  all practicing clinical psychologists this extra $137 fee?
• 3. To what extent will the ability of clinical psychologists to prescribe
  medication, provided that they have completed an approved training course,
  result in “expanded patient access to expert mental health services” (p. 267)?
                 From Last Class

•   Cognitive and behavioral processes in anxiety
•   Cognitive and behavioral treatment strategies
•   Exposure therapy
    Exposure Therapy in the Media
• Obsessed, Hoarders, My Extreme Animal Phobia,
 The OCD Project
• The OCD Project – episode footage:
• The OCD Project – standup comedy:
  Exposure Therapy in the Media
• What is the effect of this media exposure?
• Is “any publicity good publicity for exposure
           CBT for Depression

• Assess cognitive and behavioral factors that are
 contributing to the problem
• Develop cognitive and behavioral strategies to
 address them
               Nature of Depression

•       Basic psychological processes that contribute
        to depression
    •     Behavioral processes
    •     Cognitive processes
       Cognition in Depression
• Cognitive triad
   • Negative view of self, world, future
• Depressed persons engage in cognitive errors -
 tendency to interpret life events negatively
• Examples:
   • Overgeneralization
   • All-or-nothing thinking
   • Mind reading
            CBT for Depression

•   Basic clinical strategies in CBT for depression
•   Education
•   Behavior modification techniques: behavioral
•   Cognitive modification techniques
•   Integrating these: behavioral experiments

  A → B → C
Activating     Belief    Consequence
 Event                    (Emotion)
          Cognitive Restructuring

•   Disputing inaccurate thoughts
•   1. Identify the specific, inaccurate thought
•   2. Examine the evidence for alternative
•   3. Replace it with a more realistic thought
•   Goal is to eventually modify core beliefs
          Flashback to Lecture #17:
    Construct Validity of Cognitive Therapy
•    Dismantling cognitive therapy for depression:
     Jacobson et al. (1996)
•    Cognitive therapy consists of: (a) behavioral
     activation, (b) modification of automatic thoughts,
     (c) modifying core schema
•    150 patients randomly assigned to receive (a)
     only, (a) + (b), or the full treatment (a + b + c)
•    Findings and implications
            Behavioral Activation

•   Basic components
•   Self-monitoring of daily activities
•   Identifying hierarchy of meaningful, healthy
•   Gradually scheduling activities into routine
                   Behavioral Activation
“Behavioral activation. The BA treatment condition utilized in the study was an expanded version of
the approach used in the component analysis study, which was based exclusively on the
behavioral interventions recommended by A. T. Beck, Rush, Shaw, and Emery (1979). The
expanded BA model is based on a conceptualization of depression that emphasizes the
relationship between activity and mood and the role of contextual changes associated with
decreased access to reinforcers that may serve an antidepressant function. The model highlights
the centrality of patterns of avoidance and withdrawal (e.g., of interpersonal situations,
occupational or daily-life routine demands, distressing thoughts or feelings, and so forth). Because
contacting potential antidepressant reinforcers is often initially punishing, avoidance of contact
minimizes distress in the short term but is associated with greater long-term difficulty, both by
reducing opportunities to contact potentially antidepressant environmental reinforcers and by
creating or exacerbating new problems secondary to the decreased activity. Increased activation is
presented as a strategy to break this cycle. In general, BA seeks to identify and promote
engagement with activities and contexts that are reinforcing and consistent with an individual’s
long-term goals. Specific behaviorally focused activation strategies include self-monitoring,
structuring and scheduling daily activities, rating the degree of pleasure and accomplishment
experienced during engagement in specific daily activities, exploring alternative behaviors related
to achieving participant goals, and using role-playing to address specific behavioral deficits. In
addition, the expanded BA model includes an increased focus on the assessment and treatment of
avoidance behaviors, the establishment or maintenance of regularized routines, and behavioral
strategies for targeting rumination, including an emphasis on the function of ruminative thinking
and on moving attention away from the content of ruminative thoughts toward direct, immediate

                                 Dimidjian et al., 2007
Emerging Research on CBT for Depression:
Short-Term Outcomes of Cognitive Therapy vs. Antidepressants

                     DeRubeis et al., 2005
  Emerging Research on CBT for Depression:
    Long-Term Outcomes of Cognitive Therapy vs. Antidepressants

“Patients withdrawn from CT were significantly less likely to relapse during continuation than patients withdrawn from
medications (30.8% vs 76.2%; P=.004), and no more likely to relapse than patients who kept taking continuation medication
(30.8% vs 47.2%; P=.20). There were also indications that the effect of CT extends to the prevention of recurrence.”

                                            Hollon et al., 2005
CT vs. BT vs. Antidepressants: Short-Term

              Dimidjian et al., 2007
 CT vs. BT vs. Antidepressants:
Long-Term Maintenance of Gains

         Dobson et al., 2008
CT vs. BT vs. Antidepressants:
Long-Term Cost-Effectiveness

         Dobson et al., 2008
        Aaron Beck Therapy Session

• Begin at 17:40
• Cognitive therapy for a woman with depression
• Look for use of education and cognitive restructuring
• What it’s like to be a therapist using this approach?
• What it’s like to be a patient in this therapy?

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