Transcript VA Training in Cognitive Behavioral Therapy for Depression

VA Training in
Evidence-Based Psychotherapies:
Cognitive Behavior Therapy
for Depression
Gregory K. Brown, Ph.D.
VISN 4 MIRECC, Philadelphia VAMC
Bradley Karlin, Ph.D.
Office of Mental Health Services, VA Central Office
VA Psychology Training Council
EBP Workgroup
0
Background
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In recent years, health care policy has incorporated
evidence-based practice as a central tenet of health
care delivery (Institute of Medicine, 2001)

The VA developed a Mental Health Strategic Plan in
response to the President’s New Freedom
Commission on Mental Health report (2004)

The Mental Health Strategic Plan calls for the
implementation of EBPs at every VAMC in the
country
1
Goals of VA Training in EBPs
 To train VA staff from multiple
disciplines in evidence-based
psychotherapies
 To augment psychotherapies already
being offered in VA medical centers
2
VA Dissemination and
Training in EBPs
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Cognitive Behavioral Therapy (CBT) for Depression
Acceptance and Commitment Therapy (ACT) for
Depression
Cognitive Processing Therapy (CPT) for PTSD
Prolonged Exposure (PE) for PTSD
Social Skills Training (SST) for severe mental illness
(SMI)
Integrative Behavioral Couple Therapy (IBCT)
Family Psychoeducation (FPE)
– Behavioral Family Therapy (BFT)
– Multi-Family Group Therapy (MFGT)
3
EBP Presentations for Interns
and Postdoctoral Fellows
 VA EBP rollout training has been
focused on staff
 VA Psychology Training Council
(VAPTC) developed a workgroup in
2009 to focus on developing EBP
training for interns and postdoctoral
fellows
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Goals of these EBP
Presentations
 To provide a basic working knowledge
of each of the rollout EBPs
 To provide the foundation for trainees
to seek out further training and
supervision in the EBPs they intend to
implement
5
Limitations
 This presentation will not provide
equivalent training to the EBP rollouts
 This presentation will not provide the
skills to implement the treatment
without further training and
supervision
6
What is Cognitive Behavioral
Therapy?
 Cognitive Behavioral Therapy (CBT) is
a structured, short-term, presentoriented psychotherapy directed
toward modifying dysfunctional
thinking and behavior and solving
current problems.
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Why provide CBT training?
 Cognitive Behavioral Therapy (CBT)
most extensively tested psychosocial
treatments for depression
(DeRubeis & Crits-Christoph, 1998)
 CBT found to be strongly correlated
with an individuals’ changed cognitions
and their improved depression
(DeRubeis, Evans, Hollon, Garvey, Grove, & Tuason, 1990; DeRubeis, & Feeley, 1990,
Oei & Free, 1995; Oei & Sullivan, 1999)
8
Overview of CBT
 CBT is based on Lewinsohn’s
behavioral model and Beck’s cognitive
model for treating depression.
 CBT consists of 45-minute, individual
psychotherapy sessions.
 CBT is a short-term therapy consisting
of 12-16 weekly or biweekly sessions.
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General CBT Paradigm
Situation
Automatic
Thoughts
Behavior
Emotion
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Cognitive Model
11
“ABC” Model
 How thoughts influence mood (and
behaviors):
A

B 
C
Activating
Belief/
Consequence
Event
Thought
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Cognitive Model
 Situation (or activating event) may not
always be an external event.
 Situation can be a an internal event:
memory, thought, emotion, or
sensation that may prompt an
automatic thought.
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Automatic Thoughts
• They are quick, evaluative thoughts or
images that are situation specific.
• They are the most superficial level of
cognition, closest to conscious awareness.
• Patients may not be aware of the thoughts
impact on mood.
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Cognitive Model: Jack
Situation
Lost job and currently unemployed
Automatic Thoughts
“The world has screwed me over. Everyone I know
makes my life difficult. I’m better off without them.”
Reaction
Anger
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Cognitive Model: Kate
Situation
Lost job and currently unemployed
Automatic Thoughts
“My life means nothing now. I’m a horrible person.”
Reaction
Depressed
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Negative Cognitive Triad
SELF
“I am inadequate.” “I’m unlovable.”
WORLD
“The world is cruel.”
Depression
FUTURE
“Things will never get better.”
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Levels of Cognitive Processing
Core Belief
I’m incompetent.
Situation
Listening to lecture
Automatic Thought
“This is too hard. I’ll
never understand this.”
Reaction
Sad, Drops Out of Program
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Core Beliefs (Schemas)
 Most central, fundamental beliefs about
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ourselves, others, and our world
Absolute and rigid beliefs (+ or -)
Usually developed in childhood
Become active during external life events
Core Beliefs represent content (meaning)
Schemas also include cognitive processes:
Biases in attention, storage, and access of
information.
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Levels of Cognitive Processing
Core Belief
“I’m useless.”
Intermediate Beliefs
“If I’m unable to work, then I’m
useless.”
Compensatory Strategies
Focus solely on work-related
achievements
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Intermediate Beliefs
Conditional Rules or Statements (+ or -)
“If people don’t admire me, then I am a failure.”
“If I don’t complete this task perfectly, then I am
incompetent.”
“If I work very hard, then my hard work will pay off.”
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Compensatory Strategies
1. Maintaining Strategies that support the core belief
Vulnerable Belief
Aggression
2. Opposing Strategies that prove the core belief is wrong
Inadequate Belief
Overachieve
3. Avoiding Strategies that do not activate the core belief
Unlovable Belief
Avoid Intimacy
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Core Beliefs
Intermediate Beliefs
Compensatory Strategies
Situation
Automatic Thoughts
Reaction: Emotional, Behavioral,
Physiological
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CBT Case Conceptualization
EARLY
EXPERIENCES
CORE BELIEFS
Critical family members
Undiagnosed learning disability
Problems in school
“I'm no good.”
“I’m incompetent.”
INTERMEDIATE
BELIEFS
“If something doesn’t work out,
I’m a failure.”
“If I don’t try anything new,
I won’t get disappointed.”
COMPENSATORY
STRATEGIES
Avoid challenging situations.
Drug use
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Behavioral Model
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Lewinsohn’s Behavioral
Model
 Two behavioral patterns associated with
depression:
– Low rate of response-contingent positive
reinforcement, especially from others
– High rate of punishment
 Depressed individuals do not get enough
positive reinforcement from interactions
with their environment to maintain adaptive
behavior.
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Lewinsohn’s Depressive Cycle
Lack of active
engagement in one’s
environment
Depressive symptoms
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Breaking the Cycle
 Behavioral Strategies
– Increase the frequency of positive experiences.
 Break patterns of avoidance and hopelessness.
– Decrease the frequency of aversive
occurrences, if possible.
 If not possible, problem-solving approaches
can be used.
 Relationship between cognitions and
behavior is a “two-way street.”
Wright, Basco, & Thase, 2006, p. 21
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Integration of Cognitive and
Behavioral Models
Situation: Negative
Life Event
Divorce
Behavioral Response
Staying home from
work, avoiding social
interaction
Activated Beliefs
“I’m a loser. Nothing I
do works out.”
Emotional Reaction
Sad, hopeless
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BEHAVIORAL STRATEGIES
OF CBT
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Behavioral Activation
 Behavioral Activation is a simple technique for
engaging the patient in a process of change
and that stimulates positive movement and
hope.
 Therapist helps the patient to choose one or
two actions that could make a difference in
how he or she feels and then assists with
working out a plan to carry out the activity
(Wright, Basco & Thase, 2006).
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Behavioral Activation
 Use Socratic questioning to educate patient
about behavioral model of depression:
– Role of positive/negative reinforcement
– Effect of depression on engagement in pleasant
activities
– Assess the impact of pleasant activity
engagement on mood:
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Ask “How do you think this change could make you
feel?”
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Behavioral Activation
 Collaboratively, choose assignments
that are manageable.
– Match the patient’s energy level and
capacity for change.
– Be sure that it offers some challenge
without overloading the patient.
– Small steps often lead to bigger strides!
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Activity Monitoring
 Process for identifying patient’s baseline
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engagement in pleasant activities.
Depressed patients under-engage and underreport positive experiences and focus more on
failures than successes.
Write down activities no matter how mundane
using Activity Monitoring Form.
Evaluate:
– Pleasure (P): 0-10 scale
– Mastery/Accomplishment (M): 0-10 scale
– Rate overall mood for day
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Activity Monitoring Form
Mon
Tues
9-10
Shower
m-3, p-3
Shower
m-4, p-5
Shower
m-3, p-5
10-11
Walked
dog
m-4, p-5
Walked dog
m-4, p-5
Walked dog
m-4, p-5
Watched
comedy
m-0, p-7
Cleaned
room
m-6, p-3
Lunch
Lunch
(restaurant) (sandwich)
m-6, p-7
m-3, p-3
Lunch
(spaghetti)
m-4, p-4
Overall
Mood=6
Overall
Mood=4
11-12
12-1
Lunch
(oatmeal)
m-2, p-2
Overall Mood Overall
(0-10)
Mood=3
Wed
Overall
Mood=2
Thurs
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Reviewing the
Activity Monitoring Form
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Review the form with patient collaboratively.
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Goals:
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Questions:
– Use questions to guide the process.
– Help patient recognize link between behaviors/activities and mood.
– Begin to recognize pleasant and unpleasant behaviors or thematic
areas to expand upon in activity scheduling process (next step).
– “Were there periods of time when you experienced pleasure?”
– “What kinds of activities gave you pleasure?”
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Are pleasure/mastery ratings higher when spending time with
others, or in other thematic areas?
Review overall mood ratings in relation to activities (or lack
thereof):
– Ask, “Tell me about your mood on each day.”
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Activity Scheduling:
Scheduling Pleasant
Activities
 Develop structured Activity Schedule for
engaging in pleasant activities over next week
– Be concrete
 Keep it simple and achievable for specific
patient
 Relaxing and rewarding activities can have a
positive effect on co-occurring anxiety that may
contribute to depression
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Activity Schedule
Mon
Tues
Weds
Thurs
9-10
Shower
Eat breakfast
Shower
Eat breakfast
Shower
Eat breakfast
Shower
Eat breakfast
10-11
Take a 15 min
walk
Go to gym for
30 min
Take a 20 min Go to gym
walk
for 30 min
11-12
Write friend a
card
Do deep
breathing and
imagery
Identify
potential
volunteer
activities
12-1
Lunch at
favorite
restaurant
Lunch and ice Try new lunch Have lunch
cream cone
food
with friends
Call best
friend
ID possible
new hobby
Overall Mood
(0-10)
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Identifying Pleasant
Activities
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Brainstorm new rewarding and meaningful
activities:
– “What pleasurable activities did you used to do
in the past that have been stopped or reduced?”
– Incorporate information learned from Activity
Monitoring Form.
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Administer Pleasant Events Schedule (MacPhillamy
& Lewinsohn, 1982) or similar pleasant events
inventory.
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Don’t overlook simple yet pleasant activities:
– Pleasant gestures, self-care, self-promoting
activities
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Activity Scheduling:
Final Step
 Assess motivation/ambivalence, and problem
solve, as appropriate
– “How do you feel about doing this over the next
week?”
– “How likely is it that you will do this?”
– “What do you think might stand in your way of
following the schedule?”
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COGNITIVE STRATEGIES
OF CBT
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Identifying Automatic Thoughts
Basic Question to Ask During the Session:
“What was going through your mind just then?”
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Notice a shift or increased affect.
Have the patient describe a problematic situation or
time when there was an affect shift.
Have the patient use imagery to describe an event
in detail.
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Identifying Automatic Thoughts
1. What do you guess you were thinking about?
2. Do you think you could have been thinking
about _____ or ______ ?
3. Were you imagining something that might
happen or remembering something that did?
4. What did this situation mean to you?
5. Were you thinking _____?
(Therapist chooses thought that is opposite
of the expected thought)
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When Should Thought
Records Be Introduced?
 Patient is able to identify emotions (Feelings
Handout).
 Patient understands the “A-B-C” Model.
 Patient endorses the value of identifying
and evaluating thoughts.
 Therapist should verbally evaluate an
automatic thought that results in a change
in mood before introducing the thought
record.
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Introducing Thought Records
 Present the Thought Record as a “test” to
see if thoughts and emotions are really
linked.
 Talk about this as an experiment to see if
changing thinking does in fact change
feelings & subsequent behavior.
– Some patients like to think of themselves as
“detectives” or “scientists.”
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Thought Records
 Use a whiteboard, blackboard, easel or a
simple piece of paper.
 Provide a notebook or binder to write down
to record and evaluate their thoughts.
 If the patient is reluctant to write down their
thoughts and evaluations of the thoughts
[or has limited educational, language or
English speaking skills] write it for them
sitting in a side-by-side position.
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Thought Records
 Have patient select a specific, concrete
situation associated with shift or escalation
of affect.
 Patient must agree that the thought is a
high priority problem and/or feels very
upset/distressed.
 Finally, identify the sequence of what
happened that led up to the negative
emotions, thoughts, feelings and responses.
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Thought Records
 Ask the patient to describe the event in
great detail.
 Ask detailed questions or use imagery so
that the patient experiences negative
emotions during the session.
 Ask: “What was going through your mind
just then?” or “What were you thinking?”
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Stage 1: 3-Column Thought
Record
1. Use 3-Column Thought Record:
“Date,” “Event,” “Automatic Thoughts,”
and “Emotions.”
2. Write down the date and name of the
situation.
3. Write down the emotion and rate the
intensity of the emotion (0-100).
4. Write down the automatic thought.
5. Do not attempt to evaluate thoughts with
low intensity ratings (< 50-60).
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3-Column Thought Record
Date
12/18
Situation
Emotions
Automatic
Thoughts
What event led to
the unpleasant
emotion?
What emotions
were you feeling?
How intense (0100%) was the
emotion?
What thoughts
went through your
mind?
Checked the mail
Nothing but bills
No Christmas cards
Sad (80)
Lonely (90)
Nobody cares
about me.
I’ll spend the
holidays alone.
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Evaluating Automatic Thoughts
using Guided Discovery
 Therapist and patient collaboratively test
the thought’s validity or usefulness.
 Collaboratively develop an alternative or
adaptive response.
 Therapist should not directly challenge the
thought but should use collaborative
empiricism.
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Evaluating Automatic Thoughts
using Socratic Questioning
1. What is the evidence that the
thought is true? Not true?
2. Is there an alternative explanation?
3. What is the effect of my believing
this thought?
4. What should I do about it?
5. What would I tell a friend if he or she
were in the same situation?
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Using Socratic Questioning
 Never argue with patients or pressure
them to change their thoughts.
 Do not make judgmental or evaluative
comments.
 Instead, use a collaborative,
inquisitive, and curious spirit.
 Use empathy (summary statements).
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Identifying Cognitive
Distortions
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All-or-Nothing Thinking
Catastrophizing or Fortune Telling
Disqualifying the Positive
Emotional Reasoning
Labeling
Magnification and Minimization
Mental Filter
Mind Reading
Overgeneralization
Personalization
“Should” and “Must” Statements
Jumping to Conclusions
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Stage 1: 3-Column Thought
Record (review)
1. Draw four columns on a sheet of paper
and label them “Date,” “Situation,”
“Emotions” and “Automatic Thoughts.”
2. Write down the date and name of the
event.
3. Write down the emotion and rate the
intensity of the emotion (0-100).
4. Write down the automatic thought.
5. Do not attempt to evaluate thoughts with
low intensity ratings (< 50-60).
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Stage 2: 5-Column
Thought Record
1.
2.
Add two more columns: “Alternative Response”
and “Outcome.”
For the Adaptive Response:
What is the cognitive error? (optional)
1.
2.
3.
4.
5.
6.
3.
What is the evidence for this idea?
What is the evidence against this idea?
Is there an alternative explanation of the situation?
What is the effect of my believing this thought?
What should I do about it?
What would I tell a friend if he or she were in the same
situation?
For the Outcome:
1.
2.
What emotions do you feel now? How intense (0-100)?
What will you do about it?
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Thought Record Example
Date Situation
12/18
Automatic Feelings
Thoughts
Alternative
Response
Outcome
What event
led to the
unpleasant
emotion?
What
thoughts
went through
your mind?
What
emotions
were you
feeling?
Use questions to
What
evaluate the thought. emotion do
you feel now?
What will you
do?
Checked the
mail
Nothing but
bills
No holiday
cards
Nobody cares
about me. I’ll
spend the
holidays
alone
Sad (80)
Lonely (90)
Not many people
send cards anymore.
It doesn’t mean
people don’t care. I
got a call from my
cousin the other day
and I’m supposed to
go to Carlene’s for
dinner.
Not so down,
actually, more
optimistic
(50)
Still a little
lonely (30)
I’ll call a
friend and
make plans.
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Coping Cards
 3 Types
– Automatic Thought-Adaptive
Response
– Coping strategies
– Instructions to activate
(“motivate”) patient
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Coping Card: Example
 Automatic Thought:
right.”
“I can’t do anything
 Adaptive Response: “Just because one thing
I try doesn’t work out doesn’t mean I can’t
do anything. I’ve got 3 months of sobriety, I
was able to get my benefits worked out, and
I’ve been seeing my kids every week for the
past few months and it’s going well. So there
are things I’m doing right.”
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Phases of CBT
Motivational
Enhancement
Assessment
Socialization
into CBT
EARLY
CBT
Conceptualization
Treatment Goals
and Plan
Behavioral
And
Cognitive
Strategies
MIDDLE
Termination
Boosters
Follow-up
LATER
66
CBT Initial Phase
 Motivational Enhancement
 First Session: Socialization to CBT
 Establish Treatment Goals
67
Beginning CBT:
First Session Agenda
 Socialization into CBT.
 Introduce agenda setting.
 Mood check and other assessments.
 Begin to formulate specific treatment goals.
 Setting homework.
 Providing a summary and obtaining feedback.
68
Socialization into CBT
 Briefly describe CBT.
 Provide information about the efficacy of
CBT as well as other evidence-based
treatments.
 Discuss personal experiences of the efficacy
of CBT with past patients.
69
Socialization into CBT
 Review the length (16 sessions) and
frequency (weekly or biweekly) of
treatment.
 Obtain agreement for initial investment and
check-in after 4 sessions.
 Discuss the potential for negative reactions
to the session when discussing personal
issues.
70
Mood Check and Other
Assessments
 Mood Check
 Beck Depression Inventory-II (BDI)
 WHO Quality of Life (WHOQOL)
 Working Alliance Inventory (WAI)
 Medication Assessment
 Drug and Alcohol Assessment
71
Introducing the BDI-II
 Includes 21 items that assess
depressive symptoms during the past
2 weeks or since the last session if < 2
weeks.
 Circle best statement for each item.
 Total score is the sum of the highest
rating for all 21 items.
72
Beck Depression Inventory II
 Rationale for BDI assessment:
– Assesses many depressive symptoms in a brief
period of time.
– Provides an indication of depressive severity
(minimal, mild, moderate, severe).
– Provides ongoing screening of suicide ideation
and hopelessness.
– Provides a measure of treatment response.
73
Beck Depression Inventory II
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Administer at each session during consultation
process.
21 items of cognitive, affective and somatic symptoms
of DSM-IV depressive disorder.
Assumes 8th grade reading level.
Items rated on 0-3 scale for past 2 weeks but can be
adopted for the past week.
1 statement for each item is endorsed; if more than 1
statement is endorsed for an item, select the
statement with the highest score.
Total score is the sum of all 21 items.
74
Interpretation Guidelines for
BDI-II Total Score

Change in Total Score => 6 points indicates
meaningful change (+ or -):
– Ask, “Why do you think you feel less/more depressed than
last week?”

Total Score indicates level of depressive severity:
–
–
–
–
–
Score
0-13
14-19
20-28
29-63
Range
Minimal
Mild
Moderate
Severe
75
Beck Depression Inventory II
Item 9 Suicidal Thoughts or Wishes
0 I don't have any thoughts of killing myself.
1 I have thoughts of killing myself, but I would
not carry them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
76
Identifying Problems
 Identify several Target Complaints to deal
with in early stages of therapy:
– Expand on earlier information received.
– “Tell me more about the specific problems you
are having that you are seeking treatment for?”
 Work with patient to rank order the

importance of the complaints.
Then, formulate high priority complaints into
meaningful treatment goals.
77
Establish Treatment Goals
 Reframe goals in behavioral terms (such as


“How could someone tell if you were less
depressed?”).
Collaboratively choose goals that are
attainable within a brief period of time (less
than 4 months).
Prioritize the goals – very useful for agenda
setting for each session.
78
Treatment Goal Examples
 Improve depressed mood, as evidenced by
patient self-report and increased
engagement in pleasurable and masteryoriented activities.
 Improve coping with cognitive limitations
from IED explosion, as evidenced by
tolerating frustration and pursing a new
career.
79
Introduce Homework
 Describe the rationale for homework.
 Both patient and therapist will
collaborate on the homework
assignment.
 Homework will be reviewed during the
next session.
80
Introduce Homework

Examples of homework assignments
during the first session:
–
–
–
Developing Treatment Goals
Activity Monitoring
Bibliotherapy


VA Bibliotherapy Resource Guide.
Coping with Depression pamphlet.
81
MIDDLE PHASE
OF TREATMENT
General Session
Structure
82
Aims of Session Structure
during the Middle Phase
 Structuring the session is a hallmark of
CBT.
 Makes efficient use of time.
 Ensures that goals are addressed in
each session.
 Helps to link sessions together.
 Instills hope that problems can be
addressed in a systematic manner.
83
However…
 No one CT session ever follows this precise


structure.
Clinical issues may arise that require
deviation from this structure.
CBT is fundamentally a collaborative
enterprise between the therapist and
patient.
84
Session Structure
 Brief mood check & general assessment
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
85
Brief Mood Check
 Score and interpret of a standardized measure
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
(Beck Depression Inventory) or Mood Rating
on a 0-10 scale.
Conduct ongoing suicide risk assessment (if
appropriate).
Discuss adherence to treatment (medications)
and attendance of other medical
appointments.
Monitor alcohol and substance use (if
appropriate).
86
Session Structure
 Brief mood check
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
87
Bridge from Previous
Session

Ask patient to summarize previous session
or provide a summary yourself.

Rationale:
– Assesses the important aspects of therapy
that are being retained by the patient.
– Allows for any negative reactions to be
noted and discussed.
– Helps to establish the session agenda.
88
Bridge from Previous Session
 Potential Questions to Ask:
– “What did we talk about last session that was
helpful? What did you learn?”
– “Was there anything that bothered you about our
last session?”
– “Last week we talked about you doing the
homework between sessions. How did that go?”
– “Did anything happen since our last contact that
we should put on the agenda?”
89
Session Structure
 Brief mood check
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
90
Agenda Setting
 An explicit, collaborative process that occurs
between the clinician and patient.
 Rationale:
– Prioritizes problems.
– Items usually relate to treatment goals.
– Instills hope -- communicates that life’s
problems can be addressed
systematically.
91
Agenda Setting
 Potential questions to ask:
– “What do you have for the agenda today?”
– “What topics do you think are important for us to
focus on today?”
– “What would you like to work on today?”
 Write agenda down (white boards work well),

then prioritize importance.
Review of homework is usually an agenda
item.
92
Sample Agenda
1. Review homework to make two phone
calls about job possibilities.
2. Decide whether or not to continue to look
for a new job.
3. Daughter’s grades
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Agenda Setting
 Agenda setting is an ongoing part of the
session.
 At times, it will need to be revised during
the session.
 Items not discussed may be placed on the
next session’s agenda.
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Session Structure
 Brief mood check
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
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Homework Review
 In each session, spend a few minutes
reviewing what was done (or not done) for
homework because it…
– reinforces homework behavior.
– communicates that homework is
important.
– provides a basis for continued discussion
of ongoing issues.
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Session Structure
 Brief mood check
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
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Discussion of Items on the
Agenda
 Using a supportive and empathic
therapeutic approach, assess the
problem and develop a case
conceptualization.
 Once the problem is understood,
implement a cognitive or behavioral
strategy to address the problem.
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Therapeutic Relationship
Therapist is:





Empathic
Understanding
Warm
Genuine
Direct, yet sensitive
Collaborative empiricism
Guided discovery
Feedback and periodic summaries
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Achieving Balance
Empathic
Understanding
Behavioral &
Cognitive
Strategies
100
Case Conceptualization
Guides Treatment
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Behavioral Strategies
 Behavioral Activation
 Activity Monitoring
 Activity Scheduling
 Graded Task Assignment
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Cognitive Strategies
 Identifying Automatic Thoughts
 Evaluating Automatic Thoughts
–
–
–
–
Guided Discovery
Thought Records
Coping Cards
Behavioral Experiment
 Core Belief Modification
 Problem Solving Strategies
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Session Structure
 Brief mood check
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
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Periodic Summaries
 Rationale:
– Ensures that both clinician and patient have a
mutual understanding.
– Communicates empathy.
– Slows down the pacing of the session and allows
time for reflection.
– Prompts the patient to collaborate.
– Allow opportunities to modify the agenda.
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Periodic Summaries
Feeling stuck?
Then do a summary!
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Session Structure
 Brief mood check
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
107
Homework Assignment
 Rationale:
– Apply CBT skills for managing real-life problems.
– A way of encouraging patients to practice new
skills between sessions.
– Adds structure to therapy by adding a routine
item to the agenda.
 Example:
– Homework is intended to put what we discuss
into practice during the week when you are
trying to make changes in your life. We can use
our sessions to discuss how well you are doing at
trying out new things.
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Homework Assignment
 Start homework assignment in session.
 Set a date and time to complete the
assignment.
 Always write the assignment down
(Use the Homework Assignment form).
 Be careful about using the term
“homework” - May also use the terms:
“practice” or “exercise.”
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Homework Assignment
 Collaborate with the client in developing the
homework assignment:
– “Based on what we discussed today, what is
something you would like to work on this week?”
 Develop assignments that are relevant to
therapy goals.
 Choose assignments that can be
accomplished without undue stress.
– Start small and gradually increase complexity and
time required.
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Homework Assignments


Ask patients to estimate the likelihood that
they will do the homework assignment on
a scale of 0-100%.
If <90% confident, then:
1. Ask them to recall the rationale for the
homework.
2. Anticipate roadblocks and problem-solve.
3. Modify the homework assignment until 90%
confidence is reached.
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Session Structure
 Brief mood check
 Bridge from the previous session
 Agenda setting
 Homework review
 Discussion of issues on the agenda
 Periodic summaries
 Homework assignment
 Final summary and feedback
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Final Summary and
Feedback
 Ask the patient to summarize the main things
they learned or got out of the session.
 Ask what they found most helpful/least
helpful.
 Allows for assessment of progress.
 Provides opportunity to modify focus of
treatment.
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CBT Later Phase



Reviewing Progress Toward
Treatment Goals
Summarizing and Consolidating Skills
Treatment Planning
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Reviewing Progress
 Has the patient made progress toward
the specific treatment goals?
 Is the patient less depressed?
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Is the patient less depressed?
 Is the total score on the BDI lower?
– Total score decreased by 50%?
– Total score less than 10?
– No longer hopeless or suicidal?
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Is the patient less depressed?
 Are there other indications of a lower
severity of depression?
– Do patients spontaneously report that they are
feeling less depressed?
– Are they engaging in more activities during the
week?
– Do patients report that other people in their
social network notice a change in their mood or
in their behavior?
– Are the key symptoms less severe than were
initially recognized as a problem by the patient?
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Review and Consolidation
of Skills
 Ask which skills were most helpful in


reducing their depression?
Reviewing skills is useful homework
assignment because it allows time for
reflection.
If patients have difficulty generating a list of
specific cognitive and behavioral coping
strategies, then they may not be ready for
the later phase of treatment.
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Develop an Action Plan for
Setbacks and Relapses
 Normalize the experience of relapses.
 Be aware of hopelessness (about
treatment) if a setback is experienced.
 Identify issues or circumstances that
are likely to trigger a relapse.
 Develop a “survival kit.”
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Recommended Manuals




VA Training Manual: Cognitive Behavior Therapy for
Depression
(Wenzel, Brown, & Karlin, 2010)
Cognitive Therapy: Basics and Beyond
(J. S. Beck, 1995)
Learning Cognitive Behavioral Therapy: An
Illustrated Guide
(Wright, Basco, & Thase, 2006)
Mind Over Mood: Change How You Feel By
Changing The Way You Think
(Greenberger & Padesky, 1995)
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