In this chapter, you will find descriptions of:
rThe difficulties establishing a solid therapeutic relationship with persistently depressed patients
rTherapist qualities and techniques that assist in developing empathy rThe use of a questioning style in therapy with persistent depression rHow to adapt the style of therapy to regulate the intensity of affect rStructuring the use of time within therapy sessions
rProcedures that help in transferring in-session gains to the patient’s everyday life
rDifferent stages of therapy and the sequence in which different thera-peutic tasks are addressed
Few would disagree that a sound therapeutic alliance is essential to good therapy. However, the success of cognitive therapy does not rest only on the warmth and care of the therapist. Cognitive therapy aims to help patients to address their symptoms and problems through identifying and modifying maladaptive behaviours, thoughts and beliefs. The intention is to promote changes during the time-limited course of therapy that will be of some enduring benefit once therapy has ended. The nature of the relationship is therefore shaped by the need to integrate developing a sound alliance with implementing interventions to effect cognitive change. Such interventions are more likely to be meaningful, effective and enduring if patients learn to recognise and question their own thoughts. Therefore, the style in which interventions are delivered is geared to maximise the involvement of the patient in self-discovery and change. Questioning is an important aspect of this style which facilitates collaboration between therapist and patient. The precise nature of the therapeutic relationship and the style in which therapy is conducted can be viewed as foundations of cognitive therapy. The thera-peutic relationship and style of cognitive therapy distinguish it from other psychotherapies and are essential to the competent conduct of therapy.
It is important that therapy is structured to ensure that the various goals of therapy are addressed in the limited time. Cognitive therapy is structured within each session, in that different tasks are addressed at different stages of the session. It is also structured across the course of therapy, in that different goals are pursued using different strategies at different stages of therapy. The general style and structure of cognitive therapy have been described in detail in previous texts (Beck et al., 1979; Beck, J., 1995). In this chapter, we describe how aspects of the therapeutic relationship, style and structure of therapy can be adapted to address particular difficulties that emerge when applying the treatment to persistent depression. We also highlight additional aspects of therapy that can maximise the consolidation and generalisation of changes achieved.
THE THERAPEUTIC RELATIONSHIP
The practice of cognitive therapy is not possible unless the therapist is able to facilitate the establishment of a sound therapeutic relationship.
Therapist characteristics of genuineness, warmth and empathy are as essential in cognitive therapy as in other psychotherapies (e.g. Rogers, 1951). Recently, McCullough (2000) has highlighted the importance for chronically depressed patients of the experience of interacting with a
‘decent, caring human being’ in therapy. Patients with persistent depres-sion can present considerable obstacles to the conveying of warmth or care and to the development of empathy. For example, in her first few sessions, it was evident that Catherine was feeling very hopeless, did not readily accept that the cognitive model could apply to her and did not think that cognitive therapy would help. Her reluctance led the therapist to be gentle, kind and solicitous in attempting to engage her in therapy and to keep probing or confrontation to a minimum. At the end of the second session when the therapist asked how she had found the session, Catherine said irritably that she found it very upsetting and that she thought the therapist was trying to
’pin her to the ground’ emotionally. Even when the therapist believes that they have displayed ample warmth and care, the patient may experience it differently.
Challenges to Developing a Therapeutic Relationship
Avoidance of emotionally charged thoughts and feelings has a central role in the cognitive model of persistent depression. Given that focus-ing on such thoughts and feelfocus-ings is an integral part of therapy, many patients react to therapy in an aloof or even hostile fashion. Patients often
begin therapy with a conviction that the therapist cannot help and that it is therefore pointless and potentially disappointing to engage with any attempt to try. They may therefore find it hard to accept any expres-sions of warmth or caring from the therapist. The particular nature of the patients’ underlying beliefs and personal styles may also affect how they perceive warmth or care from the therapist. Highly autonomous patients or patients who see emotions as a sign of weakness may interpret the therapist’s care as a sign that they have become incapable of ’standing on their own two feet’. Expressions of warmth or caring may be taken as confirmations of inadequacy and can result in a worsening of hopeless passivity or in hostility to the therapist. Even patients who view them-selves as unlovable, and might be thought to crave warmth, may be deeply suspicious of the therapist’s apparently positive intentions. Such patients doubt that the therapist will stay positive when they discover what the patient is really like, and may try to maintain a stance of detachment in therapy.
Patients’ detachment from, or hostility towards, the therapist’s care can present a challenge to the motivation of the therapist to help. Not only do many patients not readily warm to the therapist, they also do not pro-vide any sort of stage for exhibiting technical excellence. Indeed, interven-tions that brilliantly illustrate the distorted nature of the patient’s thinking often backfire with persistently depressed patients, who may see these as designed to make them look stupid. The satisfaction of performing man-ifestly successful interventions can therefore be a long time coming. The absence of sources of ‘job satisfaction’, such as gratitude or therapeutic success, can provoke frustration in the therapist. Patients are often vig-ilant for such signs in their therapist, and may interpret them in terms of hopelessness (viz. ‘I always knew I could not be helped’) or rejection.
In addition to any sensitivity to rejection that the patient may have had before becoming depressed, they may since have had several experiences of an initially enthusiastic professional becoming frustrated and referring them on. Professional assurances designed to convince the patient of the therapist’s genuineness are thus likely to prove inadequate.
Therapists’ Personal Qualities
The therapist’s confidence in their own motivation for trying to help the patient is therefore essential. Reliance on the patient’s immediate response will undermine this, so therapists need to rely on their own resources of beneficence and patience. The latter is particularly vital, as many of the sessions are far from exciting. Maintaining motivation and concern in the face of a lack of positive response can demand considerable tenacity.
Supervision and support within the service context in which therapy is delivered (see Chapter 11) can help to build these personal resources in the therapist. Developing an affection for the foibles of this patient group can also be an asset. Therapists can be on the lookout for characteristics of these patients that touch or move them despite the frustration. For example, in filling out the question on indecision on the Beck Depression Inventory (Beck et al., 1961), one patient circled all the response options, some of them several times! Remembering this helped the therapist to maintain a certain sympathy for the internal torture of this and other patients in the face of the frustration caused by that very indecisiveness. Developing a kindly attitude to such frustrations is one of the advantages of experience that may be as important as the development of more technical aspects of competence (Persons et al., 1985).
Developing Empathy
Assuming that the therapist manages to maintain their internal sense of motivation to help, appropriately adapting the expression of warmth or care for the patient depends on the development of empathy. In acutely distressed patients, empathy is often achieved through acknowledging and reflecting the patient’s feelings. However, cognitive and emotional avoidance in persistent depression confound the conveying of empathy in this way. For patients who are emotionally flat, it is often unclear what to empathise with. Simply mirroring the emotional flatness of the patient would result in the session grinding to a halt. With an emotionally tur-bulent patient, reflecting the patient’s emotional state could result in a counterproductive escalation of feelings. In cognitive therapy, conveying empathy depends not just on the mirroring of patients’ feelings, but also on conveying an understanding of how the world looks through their eyes.
Empathy consists of accurately sensing how patients construe events in their lives, how they view themselves, and how this shapes how they feel.
Conveying this understanding when working with chronically depressed patients helps to build their trust in the therapist and in fostering their engagement. Thus, in working with a patient who eschews any emotional display, the therapist can usefully follow up any expressions of concern for the patient by acknowledging the discomfort provoked by being in therapy. For example, over the course of her first two sessions, Rosemary had described an array of problems and stresses with little outward sign of distress. At the third session, she volunteered with some agitation that her cat had just died. When the therapist tried to express sympathy, Rosemary responded rather curtly, ‘I’m fine’. The therapist ventured a ‘guess’ that perhaps Rosemary didn’t really want to go into how she felt. Rosemary
agreed with this with something of a sigh of relief and the therapist could then empathise with her worries about such feelings ‘coming out’.
Helping patients to become more aware of and better able to identify what they are feeling can contribute to developing empathy with chronically depressed patients. Some patients try not to give the therapist any ver-bal or gross non-verver-bal cues (e.g. crying) that they feel upset. The thera-pist needs to be particularly sensitive to signs of any potential affect shift, including subtle changes in tone of voice, direction of gaze or body pos-ture. Rosemary tended to describe herself as fine when discussing problem situations and would do so in a curt, clipped tone of voice followed by an attempt to return the conversation to more superficial aspects of daily living. The therapist learned to pick up on this and gently to draw her attention to it. Over time Rosemary became more able to recognise and acknowledge when all was not well with her. Other patients react catas-trophically to any sign of emotional arousal, perceiving their state simply as ‘awful’ or ‘terrible’. Helping them to discriminate between different negative emotions or different degrees of emotion can help to establish a sense that the therapist understands their feelings without criticising or rejecting them. This process of using feedback to train patients in recog-nising and labelling affective changes is prerequisite to more conventional expressions of empathy in many cases of chronic depression.
THERAPY STYLE AND THE REGULATION OF AFFECT
The style of therapy refers to the role the therapist takes in shaping the nature of the interaction with the patient. In any cognitive therapy, the therapist is active, collaborative and uses primarily a questioning format to facilitate guided discovery. The activity of the therapist is important in pacing the session appropriately. The therapist is also active in drawing rel-evant information to the patient’s attention, so that neither important prob-lems nor important assets are overlooked. Where the therapist endorses a certain viewpoint or promotes a particular activity, this is done collabora-tively through helping the patient to ascertain whether that view or action would be acceptable or helpful. Collaboration and discovery on the part of the patient are facilitated by the use of questioning to help patients come to their own understanding or draw their own conclusions. There are several ways in which different facets of chronic depression impact on the style of therapy. These include passivity in behaviour and social interaction, rigid-ity of thinking and avoidance of emotion. The style of therapy therefore needs to be adapted in order to balance the activity levels of patient and therapist, to maximise the chance of cognitive change and to manage the levels of emotion evoked in the sessions.
The Use of Questions
The passivity of many patients with persistent depression often leaves the therapist with little option other than to be even more active than usual, at least initially. This may take the form of making active suggestions as to suitable goals for the therapy or items for the session agenda or of explain-ing how the cognitive model applies to particular situations discussed.
There is a danger that this greater activity on the part of the therapist could reinforce patients’ lack of engagement in the process and thus undermine the goal of helping patients to develop ways of helping themselves. When a patient is very passive, the use of questions helps to balance increased therapist activity with fostering involvement from the patient.
Patients often find questions about their thoughts and feelings hard to answer and often take some time to do so. However, it is essential to leave the patients to answer the questions posed. Answering the question for the patient, even when the answer seems obvious to the therapist, precludes helping the patient to make cognitive and behavioural changes. Thus the therapist may need to wait very patiently for an answer or assist the patient to be able to answer. It is impossible to convey in text or transcript the style of this kind of therapy, which is slow, sometimes painfully so, and characterised by long pauses and silences. An intervention with one patient does illustrate that waiting for an answer can sometimes pay off. Over the course of the first six sessions with Simon, a number of depressive thoughts had been identified and questioned, including being ’unable’ to perform work tasks, letting down his children and being ’useless’ in the face of criticism from his wife. The therapist and patient reviewed the issues covered in therapy so far and the therapist asked:
T: Do you see any themes in what we’ve talked about so far? . . . (long pause) Do these discussions seem to have any common thread?
S: Errm . . . er . . . hmmm, I don’t know . . . yes, er . . . thought I had some-thing there but it’s gone . . . no . . . sorry, it’s erm . . . blank . . . can’t con-centrate . . . I guess, erm . . . er . . . I seem to . . . er . . . I get an emotional perception that things are really bad before I see what’s actually hap-pening . . . then even when it’s clear what’s going on I still follow the emotional side.
On saying this, the patient described a sense of seeing things more clearly (‘The penny’s dropped’) accompanied by a feeling of relief. He then took an active interest in subsequent discussion of how he expected everything in his life to go wrong and saw himself as incapable of preventing this.
The therapist can help by making questions as easy to answer as possible.
It often maximises the chances of getting answers if questions are con-crete and specific rather than abstract and general. Thus, questions about
specific sensations in the body are easier for some patients to answer than those about feelings. Similarly, questions about particular behaviours may be more productive than those about thoughts. The answers can then be followed up gradually to get information on feelings or thoughts. Another approach is to use questions that are less open-ended than usual. Patients can be provided with a choice of answers, which can take an ‘either–or’
format or be presented as a multiple choice question. For example, at his second session Stan could not generate any goals for therapy. When asked how he would like his life to be different, he spent some time pondering the question without being able to answer. Therefore, the therapist tried some more specific questions.
T: Would you prefer to be happier with your lot as it is or would you like your life to be different in some way?
S: (pause) The latter.
T: What would have to happen for your life to change?
S: (long pause) . . . I guess I’d have to fight my corner more.
T: Oh, you’d fight your corner more. How would that show itself?
S: I don’t know.
T: Do you know who you would fight your corner with?
S: Hmm . . . not really.
T: Would it be most important to do that with people close to you or people in general? Your wife, your mother-in-law, your family, people at church, at the shops?
S: (pause) I suppose it would be most important with my wife. She’s the one I spend most time with.
T: Okay, so you’d like to be a bit different with your wife. What would you do differently?
S: (long pause) Well, we always do what she wants. It would be nice to do what I want for a change.
T: Yes, and how would that happen?
S: I suppose I could ask.
T: What sort of things would you like to ask her to do?
S: I would like to go on some days out. You know, to places of interest just locally.
T: So would it be good for you to suggest to your wife ideas for days out together sometimes?
S: Yes, it would be good if I could carry them through.
Pacing of Interventions
In view of the rigidity of thinking in many patients with persistent depres-sion, gains in awareness or changes in thinking processes can be difficult to
achieve. Slow pacing and persistence are often required to implement any intervention. It is important that plausible strategies are not abandoned prematurely should they not immediately reap the intended rewards.
Interventions may need to be repeated across several sessions for any gains made to be robust. Where the aim is for patients to practise particu-lar techniques for helping themselves between sessions, the pace at which techniques are introduced needs to be adapted to the patient. For exam-ple, the methods of identifying and modifying automatic thoughts were grasped quickly over the course of two sessions by one patient, Graham, whereas with Julie three sessions and three homework assignments were spent just on identifying thoughts. When working at this slower pace, it can be difficult for both therapist and patient to see any progress. It is particularly important for the therapist to maintain vigilance for the small-est signs of changes in the patient’s behaviours or thoughts, whether in terms of successful completion of some task or just of attempting some-thing different. The therapist should greet any change, however small, with energy and enthusiasm. Not only does this provide vital reinforce-ment for the change, it can also enliven sessions that are otherwise very dull.
Regulating the Intensity of Emotions
In view of the different kinds of avoidance described in the model, the therapist has to adapt the style of therapy in order to regulate the intensity of affect within the session. In therapy with acute disorders, regulation of the intensity of emotion occurs through engaging in the different tasks of therapy. Thus, focusing on problems or painful thoughts tends to evoke distress, which can then be ameliorated by identifying coping strategies. In persistent depression, inappropriate levels of affect can interfere with many of the tasks of therapy. This interference can result from the suppression of affect or from the overwhelmingly high levels of emotion when cognitive avoidance breaks down.
In cases where emotional arousal is insufficient, it can be hard even to identify problem areas, and automatic thoughts about any problems may not be ‘hot’. When these ‘cold’ automatic thoughts are questioned, it can lead to rationalisation or rumination, rather than real restructuring or re-evaluation (see Chapter 6). The therapist needs to gear the style of therapy to increase the chance of fostering or provoking some degree of affect. The therapist must guard against coming across as overly warm or
‘touchy-feely’, as this may be perceived as aversive by the patient. It often helps for the therapist to ‘play dim’ and adopt an inquisitive style.
The therapist creates an impression that no assumptions are being made