Cognitive-behavioral treatment of depression

A three-stage model to guide treatment planning

Overholser, J. (2003). Cognitive-behavioral treatment of depression: A three-stage model to guide treatment planning. Cognitive And Behavioral Practice, 10(3), 231-239.

Depression is a complex disorder involving many different factors. Therapy may aid greatly if it is suited to the client's specific needs. Cognitive-Behavioral therapy is a three-stage model that integrates therapeutic treatments with a flexible structure that provides each patient with proper treatment to depression.

Stage one:

The core elements needed at the start of the therapy include establishing a therapeutic alliance, conducting a thorough assessment, and using differential diagnosis to guide the preliminary treatment plan.

The therapeutic relationship is largely established by events that occur during the first therapy session. It is essential for the therapist to provide a safe and supportive atmosphere that is based on trust and acceptance. The therapist can educate the client about depression in terms of its symptomatology, course and treatment.

Assessment serves a variety of functions, including: documenting the client's diagnosis, evaluating the severity of depression, developing ideas for a preliminary treatment plan, monitoring the client's progress over time, evaluating the effectiveness of treatment, and readjusting the treatment plan as needed.

Self-monitoring allows the clients to notice patterns in their mood states and reduce generalizing their days into one mood state. Clients use scales to record their mood changes throughout the week while identifying their mood type and it's intensity.

The therapist needs to establish a diagnosis of major depression according to the current diagnostic criteria. A central part of the initial assessment involves the differential diagnosis of depressive symptoms and syndromes. Differential diagnosis can help to guide the development of the preliminary treatment plan. This can help assess the need for medication.

As part of the initial evaluation, the therapist should develop a preliminary treatment plan. Therapist and client can identify several goals for treatment, emphasizing the value of building competence in areas that can help reduce depressive tendencies. Changing cognitions can promote changes in emotions and behaviors. Thus, a cognitive conceptualization can provide a framework to guide the ongoing processes of understanding the client's problems and planning the best treatment. Depressed clients are more likely to benefit from cognitive therapy when therapist and client agree on the treatment goals and therapy tasks.

Stage two:

During the second stage of treatment, different components are used for different clients. The therapist can select the modules most directly related to the client's symptoms.

For reduced activity – Behavioral activation strategies include guiding clients to monitor their daily activities, evaluating different activities for the degree of mastery and pleasure they produce, and assigning a variety of simple activities to be completed between sessions. The goal is to increase the frequency of pleasant and reinforcing activities in the client's typical day. Activities completed between sessions can provide opportunities for clients to notice the cognitions related to their negative moods.

For impaired social functioning – Therapy can help to increase the frequency of pleasant social activities in the client's typical week, improve basic social skills or assertiveness, reduce tendencies for social withdrawal when feeling depressed, and increase the amount of social support and intimacy that is experienced by the client. Clients can begin to identify and confront negative cognitions that disrupt social functioning.

For ineffective coping with recent stressors- Negative life events have been found to precede the onset of major depression. The therapist can help clients evaluate their recent coping strategies and identify effective as well as ineffective coping strategies. Clients can learn to reduce their reliance on indirect or avoidance coping strategies. Therapy can help clients learn how to tolerate negative mood states, express their emotions in constructive ways, and use these negative emotions as cues to stop, think, plan and review their coping options.

For deficient problem-solving skills – Some depressed clients display a rigid approach to problems, and tend to anticipate negative consequences from their attempts to solve the problem. As a starting point, clients need to develop an adaptive attitude toward life problems, accepting problems as a natural part of life. Some clients need to reduce their tendency to respond impulsively or emotionally and learn to think through the situation until a reasonable solution is found. The problem should be defined in terms of concrete goals that are both specific and realistic, often subdividing a complex interpersonal problem into manageable components.

For cognitive biases – Depressed patients neglect the positive parts of their life and focus on the negative aspects. Minor stressors affect clients as if they were major, which causes them to over-react to negative events. Hopelessness, worthlessness and helplessness are mainly focused on in cognitive therapy. Information about clients' life events can be brought from negative emotions.

Using cognitive therapy allows to locate, confront, and minimize depressive thinking processes. Due to the automatic occurrence of a client's thoughts, the client is taken a distance away from his own perspective. A "structured diary" acts as a self-monitoring tool that guides clients through a cognitive awareness process. Clients learn to recognize, record and eliminate maladaptive thinking processes.

Helping the patients' find positive qualities in negative occurrences and helping them shorten the delay required to reduce negative thinking processes aids their progress profoundly.

For Negative view of self – Low self-esteem is known to be connected to depression. Exploring the client's view of self is recommended and should be started by presenting semi structured worksheets and standardized questionnaires.

It is recommended to explore the client's self from a broad perspective and understand their lifestyle, as a depressive client's usually focus on a narrow and negative selection of subjects from their lives', such as only work or school.

A negative view of self may result from the client's poor performance on a subject that is significant to him or by harsh standards of the client. By using faulty comparisons and having unrealistically high aspirations, patients feel inferior to others. By focusing patients on positive aspects of self and methods of self-reinforcement, therapists encourage their clients to improve themselves.

Other issues relevant to stage two – Occasionally, therapy needs to confront predispositions of depression and its symptoms, which can be caused by abuse during childhood, neglect or loss; these are typically caused by parents. Past events may be responsible for current maladaptive cognition in patients and tending to it can promote helpful insight in the patient.

Active therapy usually starts at the 2^nd session and involves weekly therapy. Stage two ends when the client has shown significant improvement.

Stage three:

70% of the patients may recover from major depression within one year. However, depression is episodic and patients may relapse, with 75% of the patients having another depressive episode within 5 years of recovery.

Cognitive therapy has shown reduced rates of relapse in patients and less symptoms of depression after medication treatment.

An ongoing evaluation of depressive symptoms is initiated by the therapist following the warning of the client of resurfacing of depressive episodes. If warned preemptively clients may be able to identify their patterns of depressive symptoms and seek treatment.

Before therapy is terminated, the therapist seeks for risk factors. These risk factors may activate depressive relapse. After identifying these risk factors, patients prepare for mood lapses. Clients may use negative emotional states as a warning sign to start using the techniques they learned in therapy.

Therapy is used to provide the client with coping techniques for the near future and ways to deal with risky situations, while improving the patient's awareness and decision making to reduce automatic actions to events.

The patient must be aware that that negative thoughts are one side of the coin and they do not represent the true scenario. Approaching the event with humor or confidence may aid in the difficult situations.

Therapists may ask their patients to keep record of their therapy sessions, as this can be used by the patient to use these records as an instruction guide in case they are reengaged with negative thoughts. These records should show the positive aspects of the treatment and provide guidance in case the symptoms recur.

During stage three, therapy is terminated. The sessions may still be provided via phone calls or as occasional maintenance sessions. All depressed patients are addressed during the third stage.

Conclusion

Treatment of depression using the cognitive-behavioral model can be a broad tool for therapists. Each stage is addressed to different patients.

During the first stage, clients undergo an evaluation to diagnose their depression state and in order to build a treatment program.

During the second stage, the therapist conceives a treatment that fits each client's specific needs that remain within the bounds of psychotherapeutic research evidence. The sessions are made systematically and progress in accordance to the client's needs.

During stage three, relapse prevention is acquainted to the patient and measures are made throughout the entire treatment to help the patient cope with any recurring symptoms of depression.

This three-stage model integrates therapeutic treatments with a flexible structure that provides each patient with proper treatment to depression. The model may also be used to train therapists or provide support for therapists that use group formats.