question

Why would anyone want to modify CT?: CT for depression (1)

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- about 60% experience clinically significant improvement - about 40% recover - But about 25% relapse - doesn't include enough emotion - some people don't respond to it

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Why would anyone want to modify CT?: CT for depression (2)

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- so if 100 pts. get CT, probably only 30 are "cured" - and that's not factoring in --comorbidity --noncompliance & nonadherence --dropouts - so there is a need for modification, adaptations, etc. - integrative

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Unified protocol: (David Barlow) - problem

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- too many manuals and protocols for therapist to master - most pts are comorbid

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Unified protocol: solution to problem

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- design one tx for "negative affect syndrome" (depression and anxiety) - the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (Barlow et al.) - tx designed so that you can tailor emphasis for each pt

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Unified protocol: emotions

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- emphasis on emotional processing and emotion regulation - emotions are adaptive; not just something to be reduced (common criticism of CT) - emotions motivate us to engage in bxs --e.g., fear --> escape danger --problems arise when our emotional reactions don't fit the situation (e.g., can't cross bridge because fear of heights) --or when we have secondary emotional reactions to our primary emotions (e.g., shame about fear)

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Unified protocol: 7 modules - #1-4

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1. psychoeducation 2. motivation enhancement (from MI) 3. present-focused, non-judgmental emotional awareness (body scan from MBCT) 4. cognitive appraisal and reappraisal (from CT)

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Unified protocol: 7 modules - #5-7

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5. emotional avoidance and emotion-driven bxs (from experiential tradition) 6. interoceptive and situation-based emotion exposure (from BT; e.g., hyperventilate in session; write neg. thoughts) 7. relapse prevention - designed for a short-term tx of 12-18 sessions - very early stages of efficacy research

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Mindfulness Based Cognitive Therapy

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Teasdale, Segal, and Williams

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Teasdale's critique of Beck

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- Beck originally described dysfunct. schemas as trait-like (even when not activated, they are still there and should show up on measures like the DAS) - recovered pts should have more dysfunctional schemas than controls (higher scores on DAS) - but they don't

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Teasdale's modification of Beck's Theory: differential activation hypothesis (1)

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- key: what is activated when a person initially becomes depressed contributes to a vicious cycle that can lead to severe depression

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Teasdale's modification of Beck's Theory: differential activation hypothesis (2)

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- in chronic depression, depressed mood likely to reactivate negative cognitions from past depressions --so subsequent depressions may be driven more internally rather than by external stressors --this is called cog reactivity: tendency to have big cog changes in response to small changes in mood

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Teasdale's modification of Beck's Theory: differential activation hypothesis (3)

answer

- What causes some people to be more vulnerable to becoming severely depressed? --interplay of ex, social, biological, psychological --Teasdale not really focused on explaining why some people are more vulnerable in the first place: his focus is understanding how chronic depression is maintained, and devising an intervention to stop the vicious cycle

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Mindfulness Based Cognitive Therapy (MBCT)

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- developed by Teasdale, Segal, and Williams - Why there is a need for a tx for chronic depression n --20-25% of depressed pts have a chronic course --as noted before, meds usually do better than tx for this pop --but staying on meds forever is not idel - Teasdale et al. wanted to develop a maintenance version of CT - something to help people avoid recurrence of depression after completing reg CT

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The inspiration for MBSR: Jon Kabat-Zinn's Mindfulness-based stress reduction clinic (1)

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- 8 week gropu intervention for med pts with chronic pain, influenced by Buddhism - focus on mindfulness: "the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment by moment" (kabat-zinn)

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The inspiration for MBSR: Jon Kabat-Zinn's Mindfulness-based stress reduction clinic (2)

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Example interventions in MBSR: - motionless sitting: maintain position even if painful sensations arise - learn to decenter from thoughts - recognizing thoughts as thoughts "can free you from the distorted reality they often create"

question

MBCT

answer

- Teasdale et al. tried to add elements of MBSR to CT - didn't work - Revisited MBSR, realized that instructors really need to embody mindfulness themselves: acceptance and compassion - the researchers developed their own mindfulness practices and revised MBCT

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The focus in MBCT: modes of mind - doing mind

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- goal-oriented, problem solving, you can be on autopilot while in doing mind --works fine if there is a solution to be had --but if no solutions are available, doing mind leads to rumination and cog reactivity

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The focus in MBCT: modes of mind - being mind

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- experiencing, not evaluating the present moment, mindful - can't be on autopilot

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The focus in MBCT: modes of mind - goal of MBCT

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learn to access being mind through the use of mindfulness exercises

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MBCT: the tx

answer

- 8 weeks, group therapy format (lots of psychoed and mindfulness skills training) - Expected to practice mindfulness every day as part of homework

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MBCT: empirical support

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- RCT: 75 Patients: at least 2 episodes of MDD in past 5 years; not currently depressed - 2 conditions: MBCT vs. TAU --TAU: if get depressed, seek help from whomever you normally would --They found no differences between the 2 groups on other treatments received - One year of follow-up

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MBCT: evidence - who relapsed (TAU vs MBCT)

answer

- >3 episodes: 78%, 36% - 2 episodes (small group): 20, 25 - 4 or more episodes: 100, 38

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MBCT: when does it work?

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- >3 episodes: Fewer antecedent events, Earlier age of first onset, Indifference and abuse from parents - 2 episodes: More antecedent events, Later age of first onset, Normal childhoods

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MBCT: evidence of efficacy

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- Meta-analysis in 2011 found that on average, MBCT reduced risk of relapse in patients with 3 or more episodes by 43% relative to TAU - BUT--is MBCT better than an active psychological treatment? - And is the M in MBCT really the key ingredient?

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Williams et al. (2014): Dismantling study (1)

answer

- 274 patients from England and Wales - all with > 3 episodes, not currently depressed - excluded if you got CBT and it worked for you - based on earlier studies with high early attrition, added pretx engagement interview - CPE=cognitive psychological education (left out the M)

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Williams et al. (2014): Dismantling study (2) relapse rates

answer

in notes

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What do patients think of MBCT?: Allen et al. (2009) interviewed 20 of the MBCT patients one year after treatment

answer

4 themes that described their experience in MBCT: - Control: less helpless, able to understand depression, meditate to reduce "mind-churning" - Acceptance: destigmatized depression, felt understood by group - Relationships: recognized how they were putting others ahead of themselves - Struggle: acceptance vs. change

question

Mindfulness in general is popular (1)

answer

= Contrast to CT's emphasis on change: When change is difficult or impossible, focus on acceptance as a way to reduce suffering - Is this a third wave? - Not totally a new idea: REBT emphasizes acceptance; Serenity prayer from AA ("accept the things I cannot change")

question

Mindfulness in general is popular (2)

answer

- Mindfulness may be a form of exposure - Examples of mindfulness-based treatments: --DBT: mindfulness as core skill that facilitates acquisition of other skills --Acceptance and Commitment Therapy (ACT) --Mindfulness-based relapse prevention (Marlatt) --Integrative Behavioral Couples Therapy (Jacobson & Christiansen)

question

Can mindfulness be combined with CT?

answer

Not everyone thinks so: "mindfulness is essentially a mystical religious idea, based primarily on Buddhist theory and practice, and is incompatible with cognitive and behavioral theory and the CBT model of therapy" (Harrington & Pickles, 2009)

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Mindfulness out of context? (1)

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- Dimidjian & Linehan (2003): is something lost when mindfulness is separated from its roots in Buddhist and Christian contemplative traditions? - are mindful therapists better therapists?

question

Mindfulness out of context? (2)

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Is the way we train therapists compatible with teaching mindfulness? - In spiritual traditions, teacher guides student, decides when student ready to become teacher him/herself. - Group vs. individual format important for learning mindfulness? - Can therapist trainees be required to practice meditation?

question

Constructivism

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- Not exactly a therapeutic approach, rather a "unifying theme" or a "philosophical approach" that links postmodern forms of therapy - Central: epistemology, or theory of knowledge—what do we know and how do we know it? - Does not deny that there is a "real world", but that is not the focus; rather, how we construct our worlds

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Hx of constructivism: George Kelly (1905-1967)

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- Fixed-role therapy: play a role for 2-3 weeks --Discover new and more effective ways of engaging with the world - Personal construct theory --People as scientists, developing constructs to help us predict, control, and understand events in our world --Examples of personal constructs: can be anything we use to categorize people in our lives --Constructs are expressed as contrasts (empathic vs. unempathic, tall vs. short)

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Personal Construct Theory (1)

answer

We should be always revising our constructs based on our experience— "the construction system undergoes a progressive evolution" (Kelly, 1955)

question

Personal Construct Theory (2)

answer

Psychological disorders arise when we cling to constructs that no longer work for us—we fail to learn from new experiences - E.g., from experience with parents, child learns to see world in terms of abusers vs. victims, and continues to see the world this way as an adult, which interferes with developing healthy relationships

question

Kelly's Repertory Grid (1)

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- A technique Kelly developed for identifying people's constructs - One example: make a list of your parents, siblings, romantic partner, closest friend, self as you are now, and ideal self

question

Kelly's Repertory Grid (2)

answer

- Think about 3 of the above at a time, and identify how 2 of them are similar to each other, and different from the third (e.g., my mom and I are anxious and my ideal self is relaxed) - That quality you have just identified (e.g., anxious vs. relaxed) is a construct

question

Kelly's Repertory Grid (3)

answer

- Now rate all the people on your list on this construct, using a Likert-type scale (e.g., -3 to 3, with -3 being anxious and 3 being relaxed) - The extent to which you differentiate among people (using different constructs, rating each person differently on those constructs) reveals your level of cognitive differentiation—and more is better

question

Applications of repertory grids

answer

Rep grids aren't used a lot in therapy now, but they have been adopted by other fields such as business

question

Kelly and Cog Therapy

answer

- did not identify as a cognitive therapist or theorist - stressed that bx is determined primarily by attitudes, expectations, and beliefs, rather than solely ex and/or heredity. - Constructive emphasis: any event is open to a variety of interpretations

question

Michael Mahoney (1946-2006) (1)

answer

- former bx who was an early leader in the cog revolution - critiqued cog therapy's reliance on rationalistic epistemologies - disagreed with presumption that emotional adjustment was a matter of making cognitions realistic and in line with the observable world - constructivism is "a view of human beings that emphasizes their active participation in creating the meanings around which they organize their lives"

question

Michael Mahoney (1946-2006) (2)

answer

Therapy involves enhancing clients' self-awareness and helping them reconstruct an emotionally coherent sense of self across time

question

Michael Mahoney (1946-2006) (3)

answer

- How Mahoney feels he changed due to constructivism: --More nurturing, flexible, patient, tolerant of ambiguity --Trusts intuition more—both his and patient's --Sees emotions as healthy and adaptive --Sees resistance to change as part of effort to preserve systemic coherence (i.e., trying to preserve your sense of yourself)

question

Cognitive Analytic Therapy (CAT) (1)

answer

- Combines psychoanalytic object relations + cognitive psychology --Influenced by George Kelly's personal construct theory and the repertory grid --Also Neisser's Cognitive Psychology

question

Cognitive Analytic Therapy (CAT) (2)

answer

- Ryle states that CAT "avoids the reductive view of CBT" as well as "the mystifications of psychoanalysis" while still taking "the value of their contributions into account"

question

CAT: the theory (1)

answer

- We internalize child-caretaker interactions - We develop a repertoire of individual reciprocal role patterns, or procedures: we enact a role and anticipate or elicit a reciprocal response from others --Example: abuser—victim - These patterns shape our relationships with others as well as with ourselves

question

CAT: the theory (2) problem: we maintain dysfunctional role patterns due to the following

answer

- Traps: negative assumptions, which lead to problematic bxs that confirm the assumptions (similar to negative cognitions) - Dilemmas: we narrow our interpretive and bx options down to polarized opposites (like a rigid version of Kelly's constructs, seeing the world in black-or-white terms—also similar to dynamic concept of splitting)

question

CAT: the theory (3) problem: we maintain dysfunctional role patterns due to the following

answer

Snags (Subtle Negative Aspects of Goals): we abandon appropriate goals due to guilt (e.g., unconscious guilt) or predicted negative responses of others (negative cognitions again)

question

CAT: the tx (1)

answer

- Goal of treatment: "procedural change" (i.e., changing the patterns—the traps, dilemmas, snags) - Collaborative, short-term treatment (16-24 sessions)

question

CAT: the tx (2)

answer

- Around session 4: therapist writes a reformulation letter to the pt, laying out the pt's maladaptive procedures - The idea is to help the pt understand her procedures, become aware when she is falling into them, and learn to change them - the whole tx is focused on developing and then using a case formulation

question

CAT: the tx (3)

answer

Therapist also helps to change patterns by challenging the pattern through her behavior—e.g., being supportive and empathic with a patient who has learned to expect only criticism or abuse

question

CAT: research

answer

- Not much research - Only 1 RCT: Chanen et al. (2008) 15-18 year olds with 2 of 9 BPD criteria - 41 got CAT; 37 got "Good clinical care" (CBT-like treatment) - No difference in outcome, though CAT group improved more quickly - Therapists (all experienced in CBT) preferred CAT

question

CAT: an example from the reading

answer

in notes

question

CAT vs CT

answer

- Both collaborative, time-limited - Both assign HW, problem-solving - Both include detailed analysis of conscious antecedents and consequences of symptoms - CAT has been described as very similar to Schema Therapy --But more emphasis on social interaction—reciprocal roles involve how to "do" a particular kind of relationship

question

Another CAT example that wasn't assigned in the reading

answer

- client was interviewed after her tx, and she said that the key moment in therapy was when she was able to disagree with the therapist's reformulation letter, and they were able to revise it together

question

Brief Relational Therapy (BRT)

answer

Safran and Muran

question

Safran: "widening the scope of CT?"

answer

- CT in grad school - Les Greenberg: Emotion Focused Therapy - Zindel Segal: MBCT - Chris Muran: alliance ruptures and resolution - Recently published a book on psychoanalysis

question

Safran and Segal: Interpersonal Schemas (1)

answer

- Learn to regulate emotions and bxs in context of a relationship with an attachment figure - Interpersonal schema—not just schema about you or about me, but about who and how I am when I am interacting with you

question

Safran and Segal: Interpersonal Schemas (2)

answer

- We develop interpersonal schemas that help us survive childhood—problems develop when we fail to revise them in new situations --E.g., learn that can't get angry with mom and dad, so unable to express anger constructively to spouse, friend, etc.—but we still experience anger and it leaks out

question

Changing interpersonal schemas (1)

answer

- Need to become aware of them—decentering --Metacommunication: communicating about our communication—drawing patient's attention to how we are interacting

question

Changing interpersonal schemas (2)

answer

- Need to disconfirm them—which can happen through the therapeutic relationship (corrective experience) - Learn to acknowledge problems and work through them—alliance ruptures and repairs

question

Alliance Ruptures: Safran and Muran

answer

- Alliance: task, bond, goals (Bordin) - Rupture: a deterioration in the alliance, manifested by lack of collaboration on tasks and goals and/or a strain in the bond

question

Alliance ruptures: types of ruptures (Harper)

answer

- Confrontation: move against therapist - Withdrawal: move away from therapist --Or moving toward therapist, but in a way that is distancing the patient from her true position (e.g., pseudoalliance)

question

Alliance ruptures

answer

- Not just for bad therapists or bad patients—happen to everyone - Include subtle as well as dramatic - Ruptures provide opportunities --Muran et al. (2009): ruptures linked to poor outcome, but rupture resolution correlated with better treatment retention

question

Rupture Resolution

answer

- Confrontation ruptures: resolve them by accessing the patient's underlying fear/vulnerability - Withdrawal ruptures: help the patient to assert him/herself

question

Rupture resolution strategies

answer

- Metacommunication - Acknowledging responsibility ---Two-person psychology - Linking rupture to other ruptures, patterns

question

BRT: rupture resolution in tx form (looking at ruptures in great detail)

answer

Supervision: experiential, process-focused, mindfulness/awareness

question

BRT: does it work?

answer

Muran et al. (2005) ---CBT vs. BRT vs STDP for Cluster C patients ---Equivalent on outcome measures ---BRT did better with tx retention Safran et al (2005) "switch study": suggests BRT good for difficult patients who are having problems in other treatments

question

Widening scope of CT: current study at Beth Israel

answer

- First case: extern trained in CT, does 30 sessions with Cluster C/PD NOS patient - Second case: extern begins in CT again, then switches mid-treatment to Alliance-Focused Training (AFT) - Will learning about how to handle ruptures make CT therapists more effective?

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