Download Implementing treatment

Implementing treatment
Individual Treatments for Major
Depressive Disorder
The IB Syllabus Says:
• Examine biomedical, individual and group
approaches to treatment.
• Evaluate the use of biomedical, individual and group
approaches to the treatment of one disorder.
• Discuss the use of eclectic approaches to treatment.
• Discuss the relationship between etiology and
therapeutic approach in relation to one disorder.
Two individual treatments:
• Cognitive Therapy/CBT
• Psychodynamic Therapy
Individual Approaches to the treatment of depression:
Cognitive Therapy/CBT
Cognitive therapy/ CBT Etiology & treatment:
• One of the symptoms of depression is distorted
cognitions (e.g. negative self-defeating thoughts).
• This has lead cognitive psychologists to suggest
that replacing negative cognitions with more
realistic and positive one can help the depressed
person.
• This clearly demonstrates the connection between
the cognitive etiology and treatment.
Beck’s (1963) Cognitive Therapy
Outline of Beck’s (1963) Cognitive Therapy
• Aaron Beck is a pioneer in Cognitive Therapy. He developed his theory
on the early 1960s based on the idea of Cognitive Restructuring and his
theory is still at the core of many cognitive therapies (e.g. CBT).
• The key principles of this approach are to:
1. Indentify negative, self-critical thoughts that occur automatically
2. Note the connection between negative thought and depression
3. Examine each negative thought and decide whether it can be
supported
4. Replace distorted negative thoughts with realistic interpretations of
each situation
• According to Beck, a persons beliefs contribute to “automatic thoughts”
based on schemas. In depression, negative self-schemas bias a persons
thinking.
• Beck saw negative thoughts as the reason behind depression and
developed the cognitive triad. He found that depressed people tend to
draw illogical conclusions when they evaluate themselves, negative
thoughts lead to negative feelings that can result in depression. – Beck
called this the cognitive triad.
Beck’s ‘cognitive triad’ that leads to
depression (Beck, 1963)
Cognitive Behavioral Therapy (CBT)
Background:
• CBT is a brief form of psychotherapy used for the treatment of
adults and children with depression.
• In contrast to traditional forms of psychotherapy (such as
psychodynamic therapy) which are concerned with a persons
past history, CBT focuses on current issues and symptoms.
The Aims of CBT:
1. Help the client to change faulty thinking patters and
underlying schemas
2. Help the client to develop coping strategies and problem
solving skills, and to engage in behavioral activation
The CBT Procedure:
• Typically, there are around 12-20 weekly sessions, combined
with daily practice exercises specifically designed to help the
client to use new skills on a day-to-day bases. CBT is based on
Cognitive therapy (Beck, 1962) and also includes behavior
modification.
Cognitive Behavioral Therapy (CBT)
The Theory Behind CBT (theoretical framework):
• The first aim of CBT is to identify and correct faulty cognitions
and unhealthy behaviors.
• The client is encouraged to find out what thoughts are
associated with depressed feeling, and to correct them – this
is called cognitive restructuring. This is based on the
assumption that peoples interpretations and inferences about
the things that happen to them affect their thinking and
behavior.
• These cognitive processes may become distorted, but since
they are accessible to consciousness, the individual has the
power to change them.
• For example, people suffering from depression can be seen as
focusing to much on their failures. The therapist will try to refocus the clients attention on what he or she's does well and
to take note of daily successes.
Cognitive Behavioral Therapy (CBT)
Beck’s Six Patterns of Faulty Thinking:
• Beck argues that there are six patterns of faulty
thinking which lead to mental disorders such as
depression.
1. Arbitrary inference: Drawing wrong conclusions
about oneself by making invalid connections – e.g.
when it rains on the day that you have organized a
picnic, you think that only you have bad luck and
the world is against you.
2. Selective Abstraction: Drawing wrong conclusions
by focusing a single part of a whole – for example,
focusing on a single bad grade and ignoring the
fact that you actually have an A in the class.
Cognitive Behavioral Therapy (CBT)
Beck’s Six Patterns of Faulty Thinking:
3. Overgeneralization: Applying a single incident to all
similar incidents – for example, just because you have a
relationship problem with a friend means that you are
unsuccessful in relationships and have no true friends.
4. Exaggeration: Overestimating the significance of negative
events – for example, shortness of breath whilst exercising
is seen as a sign of major illness and imminent death.
5. Personalization: Assuming that others behavior is done
with the intention of hurting and humiliating you – for
example, when someone does not greet you when he or
she passes by, you assume that person is angry with you
or hates you.
6. Dichotomous Thinking: An all or nothing approach to
viewing the world – e.g. ‘you either love me or you hate
me’.
Cognitive Behavioral Therapy (CBT)
The relationship between Distorted Thinking and
Schemas
• Research has found that people with psychological
problems are often prone to negative automatic
thoughts which they cannot control. – for example
“ I never do anything right”
• Underlying the cognitive distortions is a cognitive
schema, which processes incoming information so
that it fits with biased self-perception – for
example, positive events or successes may be
filtered out to fit in with the view of the self as a
failure.
Cognitive Behavioral Therapy (CBT)
Behavioral Activation:
• The second aim of CBT is to encourage people to
increase gradually in any activities that could be
rewarding, such as sport, going to a concert, or
meeting other people. This is the behavioral
activation component of CBT
• A problem in depression is that depressed people
typically stop doing things that may potentially be
enjoyable because they think it is not worth doing
them.
• The CBT therapist can also help the client to find new
ways to deal with what seem to be big problems, by
braking them down into small steps.
Cognitive Behavioral Therapy (CBT)
The teaching of “Meta –Awareness”:
• According to Teasdale (1997) the important
feature in CBT may be to reach the clients ‘meta –
awareness’ – that is the ability to think about their
own thoughts.
• Thoughts and feelings are seen as mental events
that can be examined objectively and changed if
necessary.
• Teasdale (1997) states that the overall aim of the
therapy is to teach clients to monitor thought
processes and then to test them against reality, so
that they can eventually change their behavior.
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Evaluation: Strengths
•
Just as effective as drug treatments: Elkin et al. (1989) carried out one of the best controlled
outcome studies, conducted by the National Institute of Mental Health (NIMH) in the US to
examine the effectiveness of drug treatments in comparison to other types of therapy. They
found CBT to be just as effective as drug therapies. Furthermore, Hallon et al. (1992) found
antidepressants to equally effective and than drug treatments. CBT has also been found be very
effective for mild cases of depression.
•
Better than Placebos or No Treatment: Dobson (1989) carried out a clinical trial and found
cognitive therapy to be superior to no treatment or to a placebo.
•
CBT combined with drugs the best treatment: Nemeroff et al. (2003) found that CBT in
combination with drugs was the most effective for chronic depression in people who had suffered
from traumatic childhood experiences. This group was helped with either therapy alone or a
combination of therapy and drugs, rather than with drugs alone. However, more research is
needed to come to more reliable and valid conclusions.
•
Structure & Goals: Well structured, with clear goals and measurable outcomes.
•
Less chance of Relapse: Hallon et al, (1992) Lower relapse rates are evident in depressed
individuals who have CBT treatment than drug treatments.
•
Cost Effective: CBT is cost effective because it does not usually involve prolonged treatment(12-20
weekly sessions).
•
No Side Effects: CBT does not have the side effects that drug treatments have. No negative effects
have been found.
•
A Model for Living: The cognitive approach offers a ‘model for living’ that promotes wellness and avoids
the stigma of mental illness associated with biomedical therapies. It empowers people.
Evaluation: CBT

Evaluation: Strengths
Evaluation: CBT
• The effectiveness of CBT & SSRIs with teenagers
Aim: Riggs et al (2007) aimed to study the effectiveness of CBT in combination with either a placebo or an SSRI
Procedures: This study was a randomized double blind study with 126 adolescents (from the USA), aged 13-19, who
suffered from depression as well as a substance use disorder and a conduct disorder. Many of the participants
were recruited from the social service and juvenile justice systems. The researchers wanted to include
adolescents with substance misuse as well as depression because this group are at risk on many levels and not
much research focuses on them. Clinicians are often less willing to prescribe antidepressants to them because
they think that the adolescents should first and foremost stop abusing drugs.
Findings:
• The researchers found that the adolescents in the study complied with treatment to a large extent.
• It was not possible to follow up six of the participants, two withdrew consent and 12 could not complete the
study because their were either in jail or relocated.
• After the study participants were rated by a clinician who what that 67% of the patients in the CBT + Placebo
group and 76% of the SSRI drug + CBT group were judged as “very much improved” after being treated for four
months.
Conclusions:
• The researchers concluded that treatment with drugs and CBT is the most effective but that treatment with a
placebo and CBT is almost as effective.
• The participants self report after the study showed that depression had decreased and so had other behavioral
problems.
• The researchers argued that teaching the adolescences cognitive and behavioral techniques helped them to
manage their negative thoughts and feelings that could trigger substance abuse.
• They also say that it is important to treat adolescent depression, especially if a person suffers from another
psychological disorder as well. Treatment could start with CBT alone, and if the patient does not respond to
that, a drug from the SSRI group should be added.
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Evaluation: Weaknesses
Evaluation: CBT
Individual Differences: in order for CBT to be successful clients need to keep applying the
techniques and skills acquired in therapy. There are individual differences in participants
ability to carry on performing the techniques taught in therapy.
Self Sufficiency: The cognitive model has also been criticised because it suggests that
everyone should be self-sufficient. The Cognitive therapist Ellis (1962) had little sympathy for
those suffering with depression, regarding it as an ‘indulgence’ in self-defeating thought.
This draws attention away from the need to improve social conditions that have a significant
effect on the quality of life.
Focusing on Symptoms rather than the cause: CBT has been criticized for focusing on
symptoms rather than the cause of major depressive disorder. Beck (1991) himself has
pointed out that, although cognitive processes are involved in many psychological disorders,
they may be a consequence rather than a cause of the problems.
Ethical considerations: it has been argued that providing clients with strategies to self help,
is not as manipulative as other treatments, but some ethical issues may arise as it is the
therapist who is making judgments concerning which thoughts are acceptable. CBT also
ignores the possibility that some of the so called irrational thoughts may be true and
therefore rational.
Not an in depth-discussion: The therapy program is short, and it is it is not so helpful for
clients who want to discuss their conflicts in depth (such as in psychodynamic therapy)
Cultural issues: the therapist must be very sensitive to the clients linguistic and cultural
background for CBT to be effective.
Is it really Cost effective?: even though more cost effective than other individual therapies
(such as psychodynamic therapy which takes longer) the cost of treatment does go up when
individual rather than group therapy is followed.
Individual Approaches to the treatment of depression:
Psychodynamic Therapy
The theory behind psychodynamic therapy:
• Sigmund Freud (1915) was an influential
psychodynamic psychologist. Using evidence gained
from his case studies of people suffering from
mental disorders, Freud was convinced that mental
disorders occur because of unresolved -- usually
unconscious -- conflicts, often originating from
childhood.
• The goal of this type of therapy is for the patient to
understand and better cope with these feelings by
talking about the experiences which led to them
(catharsis).
Freud’s levels of consciousness
Conscious
The small amount of
mental activity we
know about (current
thinking processes)
pain
Preconscious Things
we could be aware of if
we paid attention to
them
Unconscious
Things we are unaware
of and plays a major
role in our behavior
Painful childhood memories are repressed to the unconscious mind (this is a defense mechanism)
Psychodynamic Therapy
The relationship between etiology and treatment:
• The Freudian psychoanalytic view relates depression in
adulthood to the individuals early relationship with
parents. Hostile feelings towards parents, its is claimed
are redirected towards the form of self-accusation and
self-hatred.
• The Psychodynamic views sees the repression of early
trauma re-emerging in adulthood in the form of
depression.
• In his theory of ‘attachment & separation’ Bowlby
(1973) proposes that separation or loss of the mother
during early childhood could result in severe
depression in adulthood.
Psychodynamic Therapy
How psychodynamic therapy works:
• Freud (1915) developed a method called psychoanalysis – often
called the ‘talking cure’. From this, many other psychotherapies
have evolved.
• These therapies seek to uncover unconscious psychodynamic
processes in order to facilitate insight into the conflicts and
anxieties that are the underlying causes of mental disorders.
• Understanding what happened in the past can help people to
better deal with situations that are happening in a persons life
now (catharsis).
• According to psychodynamic theory, the unconscious is revealed
in dreams – ‘the royal road to the unconscious’, therefore, one
of the techniques of psychoanalyse is dream analysis.
• Free association is also used where clients are encouraged to
let their thoughts wonder and say whatever comes to their
heads – the idea is that these thoughts will reveal what the
underlying conflicts are, and the analyst can then interpret a
clients behaviour based on what they say.
Evaluation of Psychodynamic Therapy
• Cost & efficiency: Eysenck (1967) proposed that the
treatment is costly, time consuming and ineffective.
• Relevance: Critics have suggested that the theory is culture
bound and has little relevance in our modern times.
• Deterministic: This model is deterministic because individuals
have very little conscious involvement in their own
personality development.
• Finding a cause: Radwan (2010) proposes that if the
depression was a result of unresolved unconscious conflicts
then Psychodynamic therapy may be very helpful in dealing
with it. By gaining an understanding of the underplaying
conflicts that caused clients are able to come up with
practical solutions that can resolve these conflicts.
• Better than CBT in the long term: Taylor (2008) proposes that
even though CBT may act quicker, psychodynamic therapy
may be more beneficial in the long term.
Individual treatments: Questions to check your knowledge and understanding:
1. What is the relationship between the etiology and treatment through Cognitive
Therapy/CBT?
2. Give an outline of Beck’s (1963) Cognitive Therapy
3. What are the Key Principles of Cognitive Therapy?
4. What is the role of schema processing in Cognitive therapy?
5. Give an explanation of Beck’s Cognitive Triad
6. Explain the Background Cognitive Behavioral Therapy (CBT)
7. What are the Aims of CBT?
8. What is the CBT Procedure?
9. What is the theoretical framework behind CBT?
10. What is behavioral activation?
11. What is the teaching of ‘Meta–Awareness’?
12. What are Beck’s 6 patterns of faulty thinking?
13. Make an evaluate point about CBT being ‘Just as effective as drug treatments’.
14. Make an evaluate point about CBT being ‘Better than Placebos or No Treatment’.
15. Make an evaluate point about ‘CBT combined with drugs the best treatment’ for CBT.
16. Make an evaluate point about ‘Structure & Goals’ in CBT.
17. Make an evaluate point about ‘Less chance of Relapse’ with CBT.
18. Make an evaluate point about CBT being ‘Cost Effective’.
19. Make an evaluate point about ‘No Side Effects’ in CBT.
20. Make an evaluate point about CBT as ‘A Model for Living’.
21. Outline the aims procedures, findings and conclusions of Rigg’s (2007) study of the
effectiveness of CBT & SSRIs with teenagers study. What are Beck’s 6 patterns of faulty
thinking?
22. Make an evaluative point about ‘Individual Differences:’ in relation to CBT.
23.Make an evaluative point about ‘Self Sufficiency in CBT’.
24.Make an evaluative point about CBT ‘Focusing on Symptoms rather than the cause’.
25.Make an evaluative point about ‘Ethical considerations’ in CBT.
26.Make an evaluative point about CBT as ‘Not an in depth-discussion’.
27.Make an evaluative point about ‘ Cultural issues’ in CBT
28.Make an evaluative point about whether CBT is really ‘Cost effective’.
29.What is the relationship between the etiology and treatment through
Psychodynamic Therapy
30.Outline the theory behind psychodynamic therapy.
31.Give an Explanation of Freud’s Levels of Consciousness.
32.Explain how psychodynamic therapy works.
33.Explain how Psychodynamic therapy is the ‘Talking Cure’:
34.Explain ‘Dream Analysis’ in Psychodynamic therapy
35.Explain ‘Free Association’ in CBT.
36.Make an evaluative point about ‘Cost & efficiency’ of psychodynamic therapy.
37.Make an evaluative point about the ‘Relevance’.
38.Make an evaluative point about the ‘Deterministic’ nature of therapy.
39.Make an evaluative point about ‘Finding a cause and psychodynamic therapy.
40.Make an evaluative point about psychodynamic therapy being ‘Better than CBT in
the long term’.
Clips..
• http://www.youtube.com/watch?v=Usnlzh8B
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