In this chapter, you will find suggestions on:
rForeseeing obstacles that might prevent patients with persistent de-pression engaging in cognitive therapy
rAdapting presentation of the cognitive model to facilitate the engage-ment of patients with firm views on the nature of their depression rIllustrating the vicious circles that maintain depression
rDiscussing underlying beliefs early in therapy
rIdentifying targets that will combat the low self-esteem, helplessness and hopelessness of patients with persistent depression
rSetting specific goals for treatment
Before interventions aimed at modifying the patient’s problems can be undertaken, a number of important tasks need to be carried out: the engagement of the patient in therapy, their socialisation into the cognitive model guiding therapy and the setting of goals for therapeutic interven-tion. In acute depression, it is usually possible to convey an understanding of the therapy within the first couple of sessions, over the course of which the patient quite naturally becomes engaged in the process of therapy. As a result of the difficulties we have outlined, in chronic depression these processes take somewhat longer and require more detailed consideration.
In this chapter, we consider some factors that require particular atten-tion in the engagement and socialisaatten-tion of chronically depressed patients into therapy. We then discuss the importance of setting goals in cognitive therapy and describe the process of setting goals with patients with per-sistent depression. We consider how appropriate goals can target the low self-esteem, helplessness and hopelessness that are central in persistent depression.
PRESENTING THE RATIONALE FOR TREATMENT
A standard feature of all cognitive therapy is explicitly sharing with the patient a cogent treatment rationale. The aim of this is to help patients to consider the possible role that their thoughts and thought processes have in maintaining their problems. Socialisation into the cognitive model is ac-complished through discussing the distinctions between thoughts, feelings and other domains of the model and outlining the way that these domains may feed into each other. It is important that the application of these ideas to a patient’s problems is then illustrated with reference to specific ex-amples from the patient’s own experience. This socialisation process also provides an important example of the collaboration and guided discovery essential to the style of therapy.
Patients with chronic depression tend to express considerable hopeless-ness and helplesshopeless-ness, and this affects their attitude to starting cognitive therapy. It is ‘par for the course’ that the therapist will not be working with a highly motivated individual brimming with enthusiasm for the therapy. A number of the other factors we have described in Chapters 1 and 3 also work against the patient readily accepting the cognitive model.
Patients may have pre-existing strongly held views about the cause of their depression that conflict with the cognitive model or they may suppress the thoughts and feelings essential to seeing the validity of the model.
Working with chronic depression, the therapist needs to be particularly active in addressing these barriers to engaging the patient in treatment.
Care needs to be taken to present the cognitive model in a way that the patient can see may be relevant to their individual problems and goes some way to accounting for the difficulties the patient is facing. During this process, it is important that the therapist does not try to per-suade the patient that cognitive therapy will help, but rather acknowl-edges their scepticism and encourages them to test the validity of the model.
Engendering in the patient a sense of hope, however small, that the therapy may be of some help will foster engagement in the therapy. Therefore, an initial attempt to present the cognitive model and discuss its relevance with the patient is usually undertaken by the end of the first session.
Initiating the socialisation process with the patient generally requires at least 15–20 minutes. There is often a danger of reaching the end of the first assessment session with insufficient time to implement this important intervention. It is usually preferable to postpone some areas of the assess-ment so that a start can be made in presenting the cognitive model at the first session.
THE VICIOUS CIRCLE MODEL
In the cognitive model, the vicious circle is viewed as an important mech-anism contributing to the maintenance of current problems. An important goal of cognitive therapy is to improve mood and functioning by slowing or breaking the vicious circle. Thus the basis of socialisation to the cognitive model is to work with the patient to construct an idea of how just such a vicious circle relates to their problems. In standard therapy with acute de-pression, this is usually addressed with reference to negative thoughts and low mood, and the interrelationship between them. Patients often readily endorse the idea that their thinking becomes more negative as their mood becomes lower, and that this then makes them feel even worse, and so on. However, as discussed on page 120, chronically depressed patients often have their own explanations for their persistent depressive symp-toms. These may be ideas that the symptoms are all biological in origin, reflect some constitutional defect or result entirely from situational fac-tors. Attempting to explain depression simply in terms of a vicious circle of thoughts and feelings may conflict with the patient’s existing ideas.
Patients who are certain that they have serious biological malfunctions or are beset by numerous social difficulties can react with outrage to any apparent suggestion that the problems are all ‘just the way they are think-ing’. When patients have had problems for years and see them as part of their make-up, they may scoff at the idea that changing their thinking will be effective or even possible. Clearly, evoking these reactions risks seriously hindering the patient’s engagement in the therapy.
When working with chronic depression, it is therefore preferable to present the cognitive model in broader terms. Using Padesky and Mooney’s (1990) generic maintenance model (see Figure 4.1) allows the interrelationships between environment, biology/physiology, thoughts, emotions, and beha-viour to be considered. Although this model is undoubtedly more com-plicated than just considering thoughts and feelings, there are distinct advantages. To ensure that this more complicated model is understood by the patient, it is important that the therapist allows adequate time for discussion and uses both verbal and written methods of presentation.
Encompassing the Patient’s Model
The aim is to socialise the patient to the model in such a way that the treatment rationale given encompasses rather than conflicts with their current model of depression. Thus the clinician needs the flexibility to emphasise differing aspects of the treatment rationale (using medication,
Environment Biology
Behaviour Thoughts
Emotions
Figure 4.1 The cognitive model showing the vicious circle in persistent depres-sion. Reproduced from Padesky and Mooney, 1990, with permission of the Center for Cognitive Therapy
modifying behaviour or unhelpful cognition etc.) according to the needs of the patient. For patients with many environmental stressors, the thera-pist can include the importance of these in contributing to depression. The therapist should thus acknowledge the social losses and difficulties that the patient has suffered, which can be considerable. Patients have frequently lost partners, friends, jobs, or homes and suffered increasing strife within relationships before or during their depression. Cognitive and emotional avoidance can make it hard for the therapist and potentially aversive to the patient to empathise fully at an emotional level with any major losses or setbacks. If this is the case, it is sufficient at this stage to engage the patient at an intellectual level with the idea that these factors are impor-tant. This can lead to the introduction of some consideration of the role of attributions and interpretations in influencing their effects. The role of cog-nitive factors can then be discussed within the patient’s existing model of depression.
For patients who believe strongly that depression is a biological disor-der, the inclusion of biology as one of the elements is vital. This enables the therapist to start from an emphasis on persistent biological symp-toms and the role these may play in the maintenance of current distress.
Moving within the model to consider thoughts about biological symp-toms can often be achieved without invalidating the patient’s model. The inclusion of biology as one of the elements also allows the therapist to account for the use of prescribed medication as a treatment intervention alongside cognitive therapy. Where patients perceive the benefits of med-ication to support a biological model, cognitive therapy is not sold as an
alternative to medication but as an additional intervention that may lead to further improvements in mood and functioning. Where patients per-ceive no tangible benefits of medication, the therapist can help them to make comparisons between symptom severity prior to the commence-ment of antidepressants and current symptom levels. Identifying any improvements, however slight, can help to illustrate the potential role of negative thinking and serve in engaging patients in the cognitive therapy rationale.
In Chapter 3 (page 124), the example was given of Peter, who stated during his first assessment that his problems were biological in nature and there-fore he did not think cognitive therapy would be of any benefit. Trying to persuade Peter that this was not the case would be likely to result in a polarised position between therapist and patient. Instead the therapist tried to place Peter’s beliefs about biological factors in depression within the above model in order to allow for other influences as well. The thera-pist first agreed with Peter that, given what his psychiatrist and others had told him, biology was very important in the origin of his depression.
The therapist then asked Peter what had made him come to the therapy session, to which the reply was that his psychiatrist had recommended cog-nitive therapy. The therapist summarised that, although Peter did not think that cognitive therapy would help, his faith in his psychiatrist’s recommen-dation put him in two minds. Peter then agreed to the therapist’s suggestion to discuss what cognitive therapy involves in order to see whether it might be of any relevance.
The therapist described the model illustrated above, placing initial em-phasis on the biological components and biological interventions. When the therapist said that it sounded like the medication had been extremely helpful in improving the symptoms, Peter replied yes and no, that the symptoms tended to wax and wane. Further discussion identified that his symptoms tended to wax and wane in relation to life events, such as his mother dying and his granddaughter being born. Asking Peter how he made sense of this, he reflected that his mother’s death had made him dwell on his childhood and how happy he had been then. When he had looked at his state now by comparison, it had made him feel very depressed for a number of months. In contrast, he had cried with happiness when he first saw his new granddaughter, and the hopeful feelings this triggered had led to some symptomatic improvement in his depression. The thera-pist asked Peter how he made sense of this experience in relation to a biological explanation. To this Peter replied that he still thought the cause was biological. However, when asked ‘Is it possible that all these factors—
biology, environment, thoughts, feelings and behaviour—together keep
the depression going?’, Peter replied ‘Yes, possibly’. The therapist then proposed an experiment to test out over the next few weeks the idea that the combination of these factors was keeping the depression going. The possibility was stressed that Peter could call it a day after that if he was still of a mind that cognitive therapy would not help. Peter readily agreed to this proposal. This agreement allowed patient and therapist to engage collaboratively in the initial stages of treatment and to develop a prelimi-nary formulation of his problems.
Breaking Down the Problems
Breaking depression down into five components (thoughts, emotion, behaviour, biology/physiology and environment) can help to combat the global, negative processing biases inherent in persistent depression.
Patients have often come to identify themselves with their depression and to see depression as a permanent aspect of their constitution. Presenting the model in terms of these five components requires the patient to consider the distinctions between the different aspects of their depression. Making these distinctions can begin to weaken this tendency of patients to identify themselves completely with the depression. This can also constitute the first step towards enabling the patient to see thoughts as thoughts rather than as immutable facts about self, others, world and future.
It is important to give consideration to which aspects of depression are placed in which domain of the vicious circle, as this can influence the clar-ity of the rationale underpinning socialisation. A problem standardly add-ressed during socialisation is the lack of distinction often made between thoughts and feelings. Patients and therapists often refer to thoughts as feelings. Patients commonly make statements such as ‘I feel a failure’ or
‘I feel so useless’. For example, Julie described a problem of poor concen-tration that affected her to the extent that she found it difficult to focus on any task. She described her reaction to her concentration difficulties in terms such as ‘I feel stupid’, which compounded her low mood and led to her either not starting activities or giving up on them very quickly. In socialising her to the cognitive model, it was helpful to view ‘I feel stupid’
as a thought rather than an emotional state. In this example, the thought that poor concentration is indicative of stupidity (‘I am stupid’) resulted in a lowering of mood (emotion). Helping Julie to relabel these ‘feelings’ as thoughts enabled their role in lowering mood to be seen more clearly. Care also needs to be taken over how to categorise cognitive deficits, such as impaired concentration and memory. These symptoms could be placed in the domain of thoughts on the grounds that they are aspects of cognition.
However, in this case one of the goals of the therapist was to help the patient to make sense of the impact of impaired concentration and mem-ory on their mood. It was therefore important to elicit the patient’s attribu-tions regarding these concentration and memory deficits. Viewing these as symptoms in the biology domain made it easier to elicit associated auto-matic thoughts and examine their impact on mood and behaviour.
How the model is communicated to the patient is important. The cognitive deficits often present in chronic depression may mean that patients find it hard to remember what has been discussed. In addition, patients’ rigidly held views can result in subsequent distortion of any conclusions. It is advisable to work with the patients to draw out the vicious circle on a piece of paper, which can be given to them to take home. As discussed in Chapter 2, information regarding the model can be supplemented by providing the patients with a handout (see Appendix 2) and an audiotape of the session. Not only does a tape help the patients to remember what has been discussed, it also provides them with an opportunity to make further observations regarding the relevance of the cognitive model to their illness. For example, one patient repeatedly apologised throughout the first assessment session that she was ‘not explaining things well’ and
‘not making sense’. Despite the therapist’s assurances that this was not the case the patient remained unconvinced. However, she listened to a tape of the session as part of her homework and at the next session she observed that she had indeed made sense. She then went on to relate this to the vicious circle discussed the previous week stating ‘I guess this is an example of my perceptions being biased’.
ILLUSTRATING THE VICIOUS CIRCLE
It is important that the model is not presented in purely generalised and abstract terms, as this may perpetuate the global and overgeneral process-ing of information characteristic of chronic depression. Once the elements of the model and relationships between them have been described in gen-eral, it is essential that they are illustrated using examples relevant to the patient’s experience. The standard examples used in cognitive therapy to share the model with the patient (e.g. you are lying in bed at night and you hear a loud noise) may be less useful in chronic depression. Using an example that is not tailored to the patient’s current problems gives the patient more opportunity to disengage from the socialisation process, claiming that the example in the metaphor is not relevant to their particu-lar circumstances. It is particuparticu-larly important to identify specific examples from the patient’s recent experiences.
The therapist should work to identify a specific, recent example of a dis-tressing time as the basis for illustrating the model. On many occasions, the patient will spontaneously have recounted during assessment a specific low point that can be used as an example. With other patients, a suitable example may have to be elicited by identifying a recent occasion when the patient felt particularly low. When the patient has difficulty with this, it can help to probe for times when they were most bothered by one of their main concerns, whether this is a physical symptom (e.g. fatigue, pain or difficulty concentrating) or external problem (e.g. debts or disagreements with family). To illustrate the vicious circle, the therapist uses a series of linked questions to identify how each of the elements was affected at the specific time and how each factor affected the others in the circle. Some useful questions for eliciting an example and information related to the factors in the model are provided below.
Socratic Questions to Elicit a Vicious Circle
rCan you recall an occasion during the last week when you felt partic-ularly depressed/anxious/guilty?
rWhere were you at the time? What were you doing? Who were you with?
rWhat happened that was so upsetting?
rHow did you feel in your body? Did you notice any bodily sensations at the time?
rAt what point in the situation did you feel most depressed/anxious/
guilty?
rAt the point where you felt most depressed/anxious/guilty what was going through your mind?
rWhat was it about what happened that made you depressed/anxious/
guilty?
rWhat did it say about you as a person?
rWhat is the worst thing you can imagine happening?
rHow did you deal with the situation?
rWhat did you do as a result?
In many cases, gathering a specific, recent example in the course of the initial assessment is easier said than done. Some patients are so overgeneral or unforthcoming that it is impossible to gain sufficient detail regarding a current difficulty to use as an example. In these circumstances, the most powerful example for illustrating the model can be low mood or anxiety evoked in the session itself. If the patient is interpersonally sensitive, the
