Intervention L1 - CBT for Depression

Question 1

What are some positives of CBT?

Answer 1

• lots of evidence of effectiveness
• manualised - can test it
• tackles cognition and behaviour and how they related
• can empower an individual so they have control over their own thoughts, to be their own therapists.
• cheap and fast - there is a specific CBT for high-risk people (e.g. suicidal) to reduce the behaviour first.

Question 2

What are some negatives of CBT?

Answer 2

• may not be the -best- therapy
• depends on the person’s own capacity to reflect on their own thinking. It won’t work if they’re intoxicated or incapacitated. Also won’t work if they’re extremely emotionally dysregulated or severely depressed - will need to use behavioural strategies first (“Behavioural Therapy”)
• relapse rate is high - but lower than for anti depressants (different across the different disorders)
• hard work, effortful - for many, going to therapy is a big effort already.
• manualised - if adhered to too closely, may leave a range of issues that a client has, unaddressed.

Question 3

What defines an empirically supported treatment?

Answer 3

• focusses on measurable aspects of specific interventions (so then it can be empirically tested)
• uses manuals to ensure adherence to treatment protocol
• tight inclusion/exclusion criteria - (to allow for clear links between diagnostic criteria and treatment - but since many people have comorbidities in real life, does the research still apply?)
• rigorously trained clinicians using therapy manuals.
• Outcomes mostly assessed on short term targeted basis (so changes in symptoms, instead of global changes or quality of life.

Question 4

What are the strengths of an empirically supported treatment?

Answer 4

• First major attempt to ensure best practice and accountability.
• Clients have a right of safe and effective treatment
• Increased confidence for practitioners that they are providing effective therapy.
• Treatment laid out in manuals, clear direction.
• For some specific problems, there is little argument that specific treatment modalities and corresponding techniques are superior.
• evidence practice has lead to improved access to psych services! eg. medicare

Question 5

Criticisms of empirically supported treatment?

Answer 5

• Rigid adherence to manual may be harmful to clients - individual differences require flexibility
• Clinical innovation reduced?
• Limited set of ESTs…
• ESTs can convey impression that only techniques matter - but in reality, we need to have a good understanding of the client and a good formulation.
Need to use the techniques and skills in a targeted manner.

Question 6

What is a formulation?

Answer 6

An understanding or model of why the client has this problem, and why it’s not going away/how it’s maintained.

e.g. phobia - negative reinforcement. Need to confront the situations and remove maintaining factor.

Put the client’s symptoms and difficulties into context, providing a foundation to use skills in a targeted manner.

Question 7

What are some aspects of CBT?

Answer 7

• Continually evolving formulation
• Therapeutic relationship is central
• emphasises collaboration and active participation
• goal oriented and problem focussed
• present focussed - can’t change what’s happened in the past, but what can we change today? how they see things.
• time-limited
• structured but not rigid
• evidence-based

Question 8

What is the first wave of CBT?

Answer 8

Behaviour Therapy.

• Focussed on behaviour
• not interested in what someone’s thinking
• modify the behaviours and the outcomes
• but not we know there are more factors involved.

Behaviourism - the environment is either rewarding or punishing, and based on that, we learn.

• Pavlov, Skinner, Wolpe.

Question 9

What is the second wave of CBT?

Answer 9

Cognitive Behaviour Therapy - combines the cognitive and behavioural view (which was established in the first wave)

Cognitivism - environment is neutral, and it’s the interpretations of those events that influence how we feel.

helps people see the world in a more helpful way, and helping them engage in a way that will help them achieve what they want in life.

Question 10

What is the third wave of CBT?

Answer 10

• ACT, Mindfulness, DBT.

Brought in more of a focus on values - what does the person really want from life? At the end of the life, what do they want it to be about?
Helpful to think about in therapy - start to take steps towards the direction

modifying unhelpful thoughts - but instead of trying to CHANGE the thought, maybe we will try to sit with the thought.

Question 11

What is the behavioural model?

Answer 11

Antecedent –> Behaviour –> Consequence

eg. Scared of dog –> Avoidance –> feel better.

behaviour is learned, primarily through environmental events. The consequence is how we learn, and how behaviours are maintained.

• Classical Conditioning and Operant Conditioning - the process by which previously neutral stimuli acquires the power to elicit a response that was originally elicited by another stimulus.

Question 12

Describe classical conditioning

Answer 12

UCS leads to UCR, but Neutral S produces no response.
after pairing UCS with Neutral S, Neutral S produces UCR.

Neutral S becomes CS, which elicits CR.

Question 13

Describe Operant Conditioning

Answer 13

• “particular behaviours become more or less likely to occur as a result of the consequences of those behaviours”

Positive and Negative Reinforcement: will increase the frequency of behaviour - it is a consequence of a behaviour that happens immediately after.

e.g., receiving pay is +ve reinforcement for working
avoiding traffic is –ve reinforcement for going to work early

Punishment & Extinction: decrease the frequency of behaviour.

Punishment = Actively applying a stimulus that decreases likelihood of behaviour eg. criticism 
Extinction = non-reinforcement of response decrease behaviour.

Question 14

What is the cognitive view?

Answer 14

• It is not the situation itself that leads to emotion, but rather the way in which the situation is INTERPRETED.
• Emotion response is mediated by interpretation of a specific situation

beliefs that we have mediate interpretations that lead to different outcomes…..

Activating event —> belief —> consequence

eg. rollercoaster - can find it fun or feel anxious if we find it scary..

Question 15

What’s Beck’s cognitive model?

Answer 15

Early experience > Dysfunctional Assumptions > Critical Incident > Assumptions Activated > Negative Automatic Thoughts (Cog Triad) symptoms

Eg. D.A. - i’m not loveable > C.I. - break up > assumption - i’m not loveable.

Question 16

What is the cognitive model?

Answer 16

We have:
- Core beliefs/ schemas of the world, which are often inflexible, and about self, others and the world.

leads to RULES and ASSUMPTIONS about what the individual ‘should do’ due to their core beliefs. “If I impress everyone… then I won’t be unloveable…”

which lead to AUTOMATIC THOUGHTS - unplanned thoughts that are a result of things happening such as “im unloveable”, which are specific to the situation, and are the most accessible thoughts.

Question 17

What are automatic thoughts?

Answer 17

• These occur in response to a specific situation
• Words or images
• Don’t appear as the result of thoughtful reasoning of introspection.
• Can be difficult to articulate - psych’s job to help them here.
• Not always aware of these automatic thoughts - can make us feel anxious all of a sudden, and we’ll realise that some thought process is going on.

Question 18

What are core beliefs?

Answer 18

Fundamental beliefs about ourselves and the world.

• Underlie and produce negative automatic thoughts
• Core beliefs influence processing of information
• Core beliefs organise understanding of self, others / world,
and future
• Not always active
• Can lay dormant until activated by a life event

• Self: “I’m unlovable”; “I am defective”
• Others: “People are out for themselves and will hurt me”
• Future: “There is no hope for the future”

Question 19

Major Depressive Disorder?

Answer 19

The criteria for a major depressive disorder (also referred to as ‘major depression’) include:
• depressed mood for more than two weeks duration.
• loss of interest in previously enjoyed activities (anhedonia).

In addition must have atleast four of the following symptoms:
• appetite disturbances
• sleep disturbances
• loss of energy nearly every day
• motor disturbances
• diminished concentration
• feelings of excessive guilt or worthlessness
• recurrent suicidal ideation

Question 20

What is the importance of therapeutic relationship in CBT?

Answer 20

• TR is the strongest predictor of outcome

- Need to be aware of client..

Question 21

What is beck’s theory of depression?

Answer 21

• Cognitive triad - negative view of the self, world and future.

Self: “I am a failure”
World: “People judge you according to your success” Future: “Things will get worse”

• Automatic negative thoughts - fleeting, but open to inspection (can help people get greater understanding of these thoughts)
  . cognitive errors -faulty thinking accompanied by negative and unrealistic representations of reality
  . schemas -pattern of maladaptive thoughts and beliefs

Question 22

What is the cognitive model of depression?

Answer 22

• People prone to depression expect that they are helpless to control aversive outcomes, and behave accordingly.
• internal, stable and global attributions are NEGATIVE EVENTS. –> i failed the exam because i am stupid (internal), i will always be stupid (Stable) at everything i do (global).
• external, unstable and specific attributions are POSITIVE EVENTS –> i only passed the exam because sally (external) helped me. it doesn’t mean i will always (unstable) be able to pass everything (specific)

Question 23

What is an example of beck’s cog model of depression?

Answer 23

Early experience - critical detached parents, who had high standards etc.

Dysfunc Assumptions - i am only worthwhile if i succeed/do well

Critical Incident - Doing bad in an exam

Assumptions Activated

NATs - i’M A FAILURE, i AM USELESS

Symptoms - withdrawn, depressed, sad, tired, poor sleep, poor concentration, less active.

Question 24

What is the behavioural view of depression?

Answer 24

• Depression is maintained because there are benefits for depressed behaviours. eg. avoidance of stressful tasks, defer responsibility to others
• depressive behaviours reinforces that behaviour and maintains depression. eg. staying home from work
• individuals with depression has withdrawn from behaviours and activities that used to provide pleasure and success.
• often withdraw from experiences that are pleasurable, no opportunity for positive reinforcement –> again, maintains depression
• poor coping skills.

Question 25

What are some psychosocial treatments for depression?

Answer 25

Cognitive Therapy for Depression (Beck et al.)
• The single most investigated psychosocial treatment for depression.
• 16-20 sessions delivered over 12-16 weeks

• Behavioural activation (doing more = feeling better. Lift your mood enough to start doing other things - cognitive therapy)
• Automatic thought identification, evaluation, and restructuring
• Deeper level schema work - dealing with chronic schemas, eg. that they’re unloveable.
• Relapse prevention

• Over numerous studies, CT is shown to be of equivalent efficacy to antidepressants, and superior to pill-placebo.

• This finding holds even when dosage is allowed to vary at discretion of prescribing
physician.

Question 26

what is cognitive restructuring?

Answer 26

• Examining the EVIDENCE!!!

• Listing evidence for and against automatic thoughts.
• Evaluate the thought taking into account the new evidence and develop a new, alternative thought that more accurately reflects the evidence on balance.
• Example: “I’m a failure” - are you really though? no one fails at everything. give EVIDENCE.

Question 27

what is behavioural activation?

Answer 27

BEST way to treat depression initially.

• Engaging a client in one or two actions can alter how they feel (lift their mood)
• Provide psychoeducation about behavioural model of depression (negative cycle of depression)
• Select actions (e.g., going for a walk) that are realistic for client
• If it is too much for the client, halve the action (e.g., if client feels overwhelmed by the thought of walking for 20 minutes a day, ask them to walk for 10 minutes)
• Helps clients to break out of patterns of withdrawal and avoidance (the factors that maintain depression)
• Develop a plan collaboratively (try not to be prescriptive)
• Ensure that the tasks are manageable
• Role-play demonstration setting up behavioural activation plan

Question 28

What is activity scheduling?

Answer 28

• People with depression tend to underreport experiences that are positive or enjoyable, and focus heavily on events that were not positive (remember cognitive profile of people with depression)

• Therefore, usually begin by monitoring clients activities, but can also be used to schedule activities for client to do in order to increase pleasure and master.

Rate activities on the following:
Pleasure (out of 10)
Mastery (out of 10) - sense of competence.

Question 29

What is the overall goal of CBT?

Answer 29

• symptom reduction
• improvement in functioning
• remission of disorder

Question 30

The three hypotheses/main propositions of cognitive therapy?

Answer 30

• ACCESS hypothesis - w/ appropriate training, motivation and attention, individuals can become AWARE of the content and process of their thinking.
• MEDIATION hypothesis - the manner in which individuals think about, interpret and construe events influences their emotional and behavioural responses.
• CHANGE hypothesis - individuals can become more FUNCTIONAL and ADAPTIVE by intentionally modifying their cognitive and behavioural responses to the circumstances they face.