Saturday, 18 February 2012

CBT for Depression - a brief overview of treatment with free resources

According to the NICE Guidelines, CBT is one of the most evidence-based treatments of choice for (unipolar) depression.  In this short article I will describe how a CBT therapist might treat depression in  a course of therapy, giving links to free off-site depression resources.

In an assessment, the therapist will screen for depression, possibly using the PHQ-9 amongst other measures to assess the level of depression and assess risk. The clinician will explain the rationale and basics of CBT for depression, often giving a handout on CBT for depression for the client to read as homework. The might also recommend self-help books to read about depression.

In the first session the therapist will start by setting an agenda, which will include reviewing the homework and starting a simple formulation of the client's depression. This may well include helping the client see if they are in a vicious cycle of depression, where low mood leads  low energy and fatigue,  leading to decreased activity and neglect of duties, feelings of guilt and hopelessness and increased depression ... The first intervention may well be activity monitoring and activity scheduling.  This will allow the therapist and client to see how active or inactive they have become and also to identify possible activities that will give them either some pleasure or sense of achievement that will lift their mood and start moving them into a virtuous cycle.
Later sessions will include cognitive restructuring, challenging negative automatic thoughts using a thought record.
Other inteventions may include problem-solving and behavioural experiments. 
For example, a behavioural experiment may test out some dysfunctional assumptions that are maintaining the clients depression - e.g. "if I go out, I won't enjoy myself" or "if I call a friend, they won't wont to speak to me.".  In some cases, it may be necessary to try to help unhelpful schemas and negative core beliefs.

In the final sessions, a blueprint will be created to manage relapse

Recommended Links - free resouces for CBT of Depression

Very Good self-help guide from MoodJuice

Excellent handout on Vicious Cycle of Depression

NICE guidelines on depression (2009 64 page PDF)
NICE quick reference guide on depression

WORD version of Activity Scheduling - grid and tips

Thought Record for Depression

Simple explanation of CBT for depression

PHQ-9 - Free Patient Health Questionnaire frequently used in NHS as quick and easy way to measure depression

First Chapter of "Depression for Dummies"

The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings - full 2003 article

2007 review of evidence for CBT for depression

Useful CBT/REBT manual for clinicians for depression
Short article expalining CBT for depression

Short handout for clients on CBT for depression

Good article on problem-solving therapy which has been shown to be effective for depression

Sunday, 5 February 2012

CBT and Behavioural Experiments

According to the bible of Behavioural Experiments,  the Oxford Guide to Behavioural Experiments in Cognitive Therapy 
"Behavioural experiments are amongst the most powerful methods for bringing change in cognitive therapy".  
In this article I will 
-  Answer the question "What is a behavioural experiment?"
-  Explain why and when to use behavioural experiments
- Give an example of a good behavioural experiment
- Advise on  some Dos and Don'ts for setting up effective behavioural experiments
- Provide further resources on behavioural experiments in CBT, including handouts and record sheets.

What is a Behavioural Experiment?

Behavioural Experiments are planned activities , based on experimentation or observation,  undertaken by clients in session or between sessions. They test existing beliefs  and/or help  test more adaptive beliefs. Their design is derived from the formulation. 
Put most simply
A behavioural experiment is when the client gets to  test something out.

Why   Why use Behavioural Experiments?
WO      Many novice  practitioners associate CBT with thought records , with just about trying to help clients think about things differently. Whilst its true that the thought record can be a powerful method, it's rarely sufficient on its own. The thought record allows the client to become more aware of their thinking and patterns of behaviour, and even to come up with alternatives. But they still may not be fully convinced that the alternatives are true. This is where behavioural experiments come in. Behavioural experiments can

          Test client’s old, negative and unhelpful existing beliefs
          Test client's ne  and more helpful beliefs 
          Enable experiential learning - "learning by doing" 
          Increase the chances that clients will say they "feel it in my heart" as well as "know it in my head"

            An example of a good behavioural experiment

For example, let's consider Julie, who has come for CBT because of difficulties with social anxiety, especially with making  presentations which she has to do at work. She has already done a thought record where she has identified the following belief
When I give a presentation it is obvious I am very nervous and everybody thinks I am a terrible presenter 
Julie believes this is true with a certainty of 90%.
A thought record gives her the alternative perspective  that this may be mind-reading and extreme thinking.
She constructs an alternative belief

               Although I am very nervous it may be that not everyone notices this and maybe some people think this I am an OK presenter

After consideration she says she believes this 25% and the original belief goes down to 75%. As a result her anxiety is somewhat reduced.Whilst this represents some progress, notice that Julie still doesn't really believe the second belief very strongly.

Julie needs to test out which belief is true - she needs to do a behavioural experiment.
Her therapist and her design the following behavioural experiment. Julie will design a survey to give to colleagues after she does her next presentation. The survey asks for two questions to be answered  honestly
1. On a scale of 0-10 (10 very nervous)  how nervous do I look when presenting?
2. On a scale of 0-10 (10 very good) how good am I at presenting?

Julie predicts she will score 9 out of 10 for nervousness and 2 out of 10 for being good at presenting.

She is amazed when she gets the feedback forms back from her survey and discovers she scores 4 out of 10 for nervousness and 6 out of 10 for being good at presenting. Notice that her colleagues don't say that she is completely nerveless or that she is a fantastic presenter - but they say enough to disprove her extreme thinking.

When asked to re-rate her original beliefs she now says rerates the positive belief at 75% and the more negative belief only 25%

As if often the case, a behavioural experiment has made a much greater impact that thethought record.

Some Dos and Don'ts for setting up effective behavioural experiments

*         Plan experiments thoroughly don't just say "why don't you try it out"?
*      Find out what beliefs are being tested, and how much the client believes them now
*      Be specific about what the client will do, where and when
*      Think about what problems are likely to be encountered and how to deal with them
*       Set up experiments to be  “no-lose” – we learn whatever happens
*          After the experiment, explore the outcome – what happened, which beliefs were vindicated, what the client has learnt – how much their beliefs have changed
*      Be enthusiastic and positive about the clients efforts and stay curious 
*      Finish by asking "what's the next step?"

More good free resources on Behavioural Experiments in Cognitive Therapy
Introductory chapter (Historical and conceptual underpinnings) from Bennett-Levy, Butler, Fennell, Hackmann, Mueller  & Westbrook  Oxford Guide to Behavioural Experiments in Cognitive Therapy

Chapter on Behavioural Experiments for Depression by Fennell, Bennett-Levy & Westbrook from their book  Oxford Guide to Behavioural Experiments in Cognitive Therapy (Chapter 10)

Good handout on behavioural experiments to give to clients

Good powerpoint presentation on Behavioural Experiments

Behavioural Experiment Worksheet

Another behavioural experiment worksheet from Good Medicine (recommended site)

Good  Behavioural Experiments   FAQ

Video demonstration of  setting up a behavioural experiment

Manual including behavioural experiments for Chronic Fatigue Syndrome (CFS) and ME

Systematic review suggesting some evidence that behavioural experiments may be more effective than exposure alone