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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_205_библиотеки_им_акад_М_И_Перельмана
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PART V
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Psychotherapy of
Mood Disorders
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CHAPTER 23
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Cognitive and
Behavior Therapies
for Depressive Disorders
W. Edward Craighead, Ph.D.
Evidence-based psychotherapies for the acute treatment of major
depressive disorder (MDD) include Beck’s eponymous cognitive-behavior therapy
(CBT; Beck et al. 1979) and behavioral activation (BA; Jacobson et al. 2001), a contemporary form of behavior therapy. These therapies are short-term, educational, and
fairly directive, typically comprising 16–20 sessions over 12–16 weeks. This chapter
focuses on the description and clinical outcomes of BA and CBT, the most extensively
evaluated of the efficacious psychotherapies. Notably, there are only minimal outcome data to support the choice of one over the other of these two therapies. Consequently, the decision regarding which of these therapies to implement is based on the
therapist’s competence, availability, and preference as well as the patient’s treatment
preference.
BA and CBT psychotherapies were derived from theoretical models and empirical
psychopathological evidence regarding the etiology and maintenance of MDD. Behavior therapy (BT) was developed during the 1950s–1960s when mental health care
professionals began applying empirically derived principles of learning theory to
clinical intervention processes. BT and CBT (which began in earnest during the 1970s)
are now mainstream models of psychosocial clinical interventions. Training in these
conceptual models and their related interventions is a focus of most doctoral training
programs in clinical psychology. Because the therapies are entirely compatible with
biological models of contemporary psychiatry, training and clinical use of these therapies, along with interpersonal psychotherapy (IPT), are included in most psychiatry
training programs.
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406 The APA Publishing Textbook of Mood Disorders, Second Edition
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BT derived from the conceptual framework of behaviorism, which may be traced
to a variety of influences from around the world. In the United States, John B. Watson
(1878–1958), who defined psychology as the “science of behavior,” is most often cred
ited with changing the focus of psychology from the study of the “mind” to the study
of observable behaviors. Behaviorism became the primary conceptual framework un
derlying most basic psychological research from the 1920s through the 1970s.
Although occasional evaluations of a behavioral intervention were undertaken at
earlier dates, extensive implementations and appraisals first emerged during the 1950s
and 1960s (W.E. Craighead et al. 1995). The primary defining characteristic of BT was
the application of principles of behaviorism to clinical phenomena as psychology
moved from the basic science laboratories to informed clinical interventions. Two basic
learning theory principles guided the development of BT: 1) principles of operant con
ditioning (first labeled behavior modification, now commonly called applied behavior
analysis), championed by Skinner (1953) and his colleagues; and 2) principles of clas
sical conditioning, applied (at least metaphorically) by Wolpe (1958) in his description of behavioral treatments for anxiety. Because anxiety was viewed as the core of
“neuroses” within the then-prevailing psychodynamic model of psychopathology and
treatment, BT initially focused on treatment of “anxiety” problems. Soon thereafter,
clinical applications were developed for a variety of other disorders. The empirical
evaluation of BT interventions, a fundamental hallmark, sustained BT and supported
its efficacy for a wide range of clinical disorders (L.W. Craighead et al. 1994; Kazdin
1994).
During the 1970s, a confluence of factors resulted in a large proportion of behavior
therapists shifting their focus to internal cognitive processes, producing the therapies
now subsumed under the rubric of CBT. Like BT, CBT has not been monolithic; there
are more than 20 different CBT approaches (Mahoney and Lyddon 1988), even when
the so-called third-wave approaches of BT (e.g., mindfulness, dialectical behavior
therapy; see Öst 2008) are omitted. CBT therapies emerged from three major developments. First, empirically oriented clinicians applied basic cognitive psychology constructs to the blossoming models and procedures of clinical intervention (e.g.,
Bandura’s [1969] use of information processing in espousing his social learning the
ory). Second, the reformulation of behavioral self-control procedures as cognitive interventions influenced CBT (e.g., Meichenbaum 1977; Thoresen and Mahoney 1974).
Finally, Ellis’s (1962) and Beck’s (1964, 1970) identification of cognitive therapies occurred in their clinical settings. Cognitive therapies, based on clinical experience
rather than findings from basic psychology, rapidly lent themselves to empirical clinical trials. Ultimately, Beck and colleagues (e.g., Beck et al. 1979) combined BT and
cognitive therapy into CBT.
BT and CBT share two cardinal assumptions: basic psychological research informs
clinical models and procedures, and clinical scientists must evaluate the efficacy and
effectiveness of interventions. Both BT and CBT (and IPT) are compatible with appropriate medication interventions in treating depression (W.E. Craighead and Dunlop
2014). The major difference between BT and CBT lies in the conceptualization of the
psychopathology and the resulting specific intervention programs for various clinical
disorders.
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Individual Behavior Therapy
Several variants of BT were developed for the treatment of MDD; they all, however,
shared the assumption that MDD results from avoidant coping strategies and de
creases in behaviors that result in positive reinforcement. Consequently, behavior
therapies for depression have focused on monitoring and increasing positive daily ac
tivities, decreasing negative life experiences, improving social and communication
skills, and increasing adaptive behaviors such as assertiveness, as well as increasing
adaptive behaviors resulting in response-contingent positive reinforcement.
Early Behavior Therapy
During the 1970s and early 1980s, Lewinsohn and his colleagues demonstrated that
BT reduced aversive experiences and increased pleasant experiences—changes that
resulted in decreased depression symptomatology (see summary in Lewinsohn and
Gotlib 1995). Other investigators compared BT with the then-accepted antidepressant
medication treatments. They found that BT was as effective as tricyclic antidepressants in reducing depression during a 12-week treatment period. During a 6-month
follow-up, they found that acute BT treatment effects were maintained when patients
were given essentially monthly booster sessions (Bellack et al. 1981, 1983; Hersen et
al. 1984).
In 1979, McLean and Hakstian created an expanded BT by adding problem solving
and Rehm’s self-control (Rehm 1977) procedures. They completed a 10-week clinical
trial comparing their expanded BT to relaxation therapy, insight-oriented psychotherapy, and amitriptyline. The expanded BT program was equal or superior to the other
treatments. These outcomes were maintained at a 27-month follow-up, when individ
uals in the BT group were more socially active and productive than those in the other
treatment conditions (McLean and Hakstian 1990).
In a consequential study, Keller et al. (2000) treated 681 adults with chronic MDD
(MDD of at least 2 years’ duration), current MDD superimposed on a preexisting dys
thymic disorder (“double depression”), or recurrent MDD with incomplete remission
between episodes and a total of at least 2 years’ total duration of continuous illness.
Patients were randomly assigned to receive 12 weeks of treatment with either an antidepressant (nefazodone), cognitive-behavioral analysis system of psychotherapy
(CBASP), or the combination of CBASP and nefazodone. CBASP (McCullough et al.
2000) focuses on the consequences of the patient’s behavior and the use of social problem solving to address interpersonal difficulties. Patients receiving nefazodone exhibited a more rapid reduction in symptoms during the first 4 weeks of treatment, but by
the end of 12 weeks of treatment the outcomes were equivalent for the CBASP and
nefazodone groups. Importantly, at the 12-week posttreatment assessment, the combi
nation of CBASP and nefazodone was superior to either monotherapy intervention.
Nemeroff et al. (2003), in a subsequent analysis of the study data, reported that CBASP
(either alone or in combination with nefazodone) was an essential ingredient in the
successful treatment of depressed patients who had experienced early life trauma.
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Behavioral Activation
More recent iterations of BT for depression emanated from the work of Jacobson (for
a review, see Dimidjian et al. [2011), who in a dismantling study of CBT, sought to
identify its efficacious components for treating depression. Jacobson et al. (1996) eval
uated the hypothesized mechanisms of change by randomly assigning depressed
patients to one of the following three conditions: 1) the full CBT intervention (i.e.,
BA+automatic thoughts (AT)+schema work); 2) BA plus modification of distorted
AT; or 3) BA alone. Like earlier BT, the BA treatment focused on decreasing avoidance
(defined as a maladaptive coping strategy to avoid emotional stressors). To combat
avoidance, BA included techniques such as monitoring daily activities, assessing
pleasure in and mastery of activities, assigning increasingly difficult activities, imag
ining behaviors to be performed, discussing specific problems and identifying behavioral solutions to those problems, and intervening to ameliorate social skills deficits.
Jacobson et al. (1996) found that BA alone and the full CBT treatment package were
equally efficacious after the 20-session acute treatment trial and at 6-month followup. The treatment outcomes were maintained over a 2-year follow-up period—patients in all three treatments had equivalent rates of relapse, time to relapse, and number of symptom-free weeks (Gortner et al. 1998).
Jacobson and colleagues subsequently undertook a larger randomized trial comparing BA, CBT, paroxetine, and pill placebo. The placebo condition was maintained
for 8 weeks. Paroxetine was found to be superior to placebo for the severely depressed
patients; there were no differences between paroxetine and pill placebo for the more
moderately depressed patients. At the end of the 16-week treatment, BA was equal in
effectiveness to paroxetine among severely depressed patients, and both treatments
were slightly superior to CBT (Dimidjian et al. 2006). A 2-year follow-up (Dobson et
al. 2008) indicated that both BA and CBT were superior to paroxetine (even after be
ing administered for 12 months) in maintaining the acute treatment effects. By illustrating the efficacy of BA across the MDD severity spectrum, these findings raised
questions about the practice guidelines positing that only medication treatments are
effective for severely depressed patients (American Psychiatric Association 2010).
Because of the apparent relative ease of conducting BA compared with CBT and IPT,
there is widespread belief that BA can be more easily disseminated, a benefit that
would be especially valuable to countries with limited mental health care services. This
suggestion seems meritorious, given that Patel and colleagues have directed successful
implementations of BA by less extensively trained local personnel in India (Patel et al.
2017, 2019). It should be noted, however, that the choice of 5–8 weekly sessions (instead of the typical 16 + weekly sessions) and the content of those 5–8 sessions remain
unclear. Furthermore, the outcome measures included only brief self-report measures
(e.g., the 9-item Patient Health Questionnaire [PHQ-9]; Kroenke et al. 2001) covering
a relatively short period of time. Nevertheless, recent dissemination implementations
in low- and middle-income countries show promise and are clearly needed.
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Summary
Consistent findings support the efficacy of BT for MDD. Repeated meta-analyses
have concluded that BA is at least as effective as CBT and antidepressant medications
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in treating MDD to remission (Cuijpers et al. 2007; Ekers et al. 2014; Huguet et al. 2018;
Mazzucchelli et al. 2009). Nevertheless, for many years BT was overshadowed by out
come studies that focused on CBT and IPT as psychosocial interventions for MDD.
However, given the relative efficacy, efficiency, and endurance of behavioral interven
tions and the recent results supporting the efficacy of CBASP and BA, it seems that
this was an infelicitous turn of events. From a historical perspective, the lack of atten
tion to BT was likely due to the unfortunate exclusion of BT from the influential Treatment of Depression Collaborative Research Program (TDCRP; Elkin et al. 1985) rather
than the relative scientific merit and empirical outcomes of the then-extant compara
tive treatment studies.
Individual Cognitive-Behavior Therapy
As described earlier, CBT emerged as an amalgamation of three different developments: cognitive therapies per Ellis (1962) and Beck (1970, 1976); self-control and selfinstructional training therapies (Mahoney 1974; Meichenbaum 1977); and the cogni
tive revolution in basic psychology theory and research that led to cognitively based
interventions (Dember 1974). Early in the 1970s, there were several small studies uti
lizing some form of CBT, but it was Rush et al.’s (1977) extraordinarily important
study that was largely responsible for the technique’s inclusion in the TDCRP com
paring CBT with IPT, pill placebo, and imipramine (Elkin et al. 1989). CBT rapidly became a viable treatment for MDD, at least partly because of its inclusion in the TDCRP
and in Beck et al.’s (1979) manual written for that study.
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Description
The typical CBT model (Figure 23–1) comprises three cognitive components: negative
self-statements, cognitive errors, and underlying schemas or core beliefs. Within the
model, MDD typically follows the occurrence of a life event; however, it is the com
bination of resulting automatic thoughts, information-processing deficits (cognitive
errors), and enduring negative cognitive patterns (schemas/core beliefs) that leads to
the development and maintenance of depression. CBT, consequently, focuses on assisting patients in changing their automatic statements, cognitive processes, and fundamental beliefs so they become more adaptive, positive, and internalized.
Automatic Thoughts
AT originate in response to a prompting event. One does not work to generate these
thoughts, so they are labeled “automatic,” as in springing up “naturally” and without
effort. Beck et al.’s (1979) CBT manual noted that depressed individuals engage in
negative AT or self-statements about themselves, the world, and the future (frequently referred to as the cognitive triad). Although depressed individuals can generally gain awareness of these thoughts, they typically are unaware of two things—
their thoughts contain errors or distortions, and these AT serve to maintain or exacerbate negative mood. Depressed individuals do not view their AT as invalid (even
when they are inaccurate), so their emotional responses to these AT are the same as if
the AT were actually true.
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Life event
Automatic
thoughts
Cognitive
errors
Core beliefs
(schemas)
Depression
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FIGURE 23–1. Cognitive model of depression.
Cognitive Distortions
As just described, the CBT model maintains that depressed thinking is negatively biased and automatic; additionally, and at a deeper level, depressed thought processes
are also fraught and replete with cognitive distortions and processing errors. Cogni
tive distortions and errors may be activated by continuous negative self-statements,
or they may surface from activation of the individual’s underlying core beliefs or self
schemas. Cognitive distortions serve the role of processing errors that function, along
with schemas, to screen out positive information or to process negative or neutral in
formation in a negative manner.
ples of frequently occurring cognitive errors, including the following: 1) all-or-nothing
thinking—viewing things in black-and-white terms rather than as existing on a con
tinuum; 2) arbitrary inference—drawing negative conclusions in the absence of corroborating evidence; 3) overgeneralization—drawing conclusions that far exceed the
bounds of the current situation; 4) selective abstraction—concentrating on one detail
(typically negative) about a situation and ignoring others, thereby failing to see the
whole picture; 5) magnification/minimization—magnifying the negative aspects of a
person or situation and minimizing the positive aspects; 6) personalization—believing
that external events happen because of one’s own inherent inadequacy, weakness, or
other flaw, thereby disregarding contradictory evidence; 7) emotional reasoning—
thinking something must be true because of the strength of the feeling associated with
the thought.
Both A.T. Beck (1976) and J.S. Beck (1995) identified and described several exam-
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Core Beliefs (Schemas)
Beck (1976) postulated that depressed individuals utilize stable and negative cognitive patterns when interpreting information from their environments. These enduring patterns derive from fundamental beliefs—that is, depressed individuals’ a priori
assumptions about themselves. Beck and others (e.g., Young et al. 2003) refer to these
fundamental beliefs as schemas. These depressogenic schemas become activated ei-
ther directly by a major negative life event or indirectly through AT and cognitive
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processing errors about a life event. Sacco and Beck (1995) noted that the CBT theory
of depression exemplifies a diathesis-stress model, wherein depressogenic core be
liefs/schemas develop earlier in life (diathesis) and are latent until activated by negative life events (stress).
Process of CBT
A short-term (16–20 sessions over a period of 12–16 weeks), directive, and educational
therapy, CBT attempts to change the depressed patient’s negative view of the self, the
world, and the future. The ultimate and essential goal of CBT is to correct the patient’s
long-standing pattern of faulty underlying core beliefs/schemas. Each session begins
with the therapist, in collaboration with the patient, setting an “agenda” for the session.
Over the course of treatment, CBT therapists consistently employ Socratic dialogue and
freely use metaphors in discussing cognitive errors and correcting faulty beliefs.
Session 1 focuses on gathering the patient’s history and achieving a correct diagnosis. During the second or third session (depending on the time necessary to complete history and diagnosis), the therapist presents the treatment rationale, designed
to inform the client of the cognitive formulation and conceptualization of MDD as
well as the upcoming processes of therapeutic sessions and change (Beck et al. 2001).
Once the rationale is understood and accepted, early CBT sessions employ BT inter
ventions. Various and controversial opinions exist regarding the purpose of the early
behavioral interventions. Cognitively oriented CBT therapists maintain that the only
purpose of behavioral strategies is to provide opportunities for monitoring behaviors
and their associated thoughts and feelings; behavioral changes are not posited to be
directly responsible for decreases in depression as BT therapists might view their im
pact (see Ilardi and Craighead 2006). During the third or fourth session, the therapist
introduces self-monitoring techniques to help the patient gain an awareness of the re
lationship between AT and feelings. As the patient acquires a better understanding of
this relationship, the therapist shifts to assisting the patient in developing alternative
thoughts and identifying the resulting new feelings. Subsequently, patients are taught
to perceive how their AT relate to their thought processes and logical errors, including
the cognitive errors listed above. The middle sessions of CBT focus on identification of
cognitive processing errors and mechanisms to correct the erroneous thought processes. Slightly over halfway through the therapy (typically sessions 9–10), the therapist introduces the concept of schemas, the beliefs underlying negative and positive
thoughts and cognitive processes. Gradually, therapy focuses on changing these negative schemas (e.g., “I am worthless,” “I am unlovable”), which are posited to play a
central role in precipitating and maintaining major depressive episodes. Near the end
of therapy (sessions 14–16), the focus shifts to termination and the use of cognitive
strategies to prevent relapse or future recurrences of MDD.
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CBT Outcome Data
CBT remains the most extensively evaluated and highly scrutinized psychosocial
treatment for MDD. A number of early randomized controlled trials (RCTs) compared the relative effectiveness of CBT and tricyclic antidepressant medications
(ADMs) (Elkin et al. 1989; Hollon et al. 1992; Rush et al. 1977; Simons et al. 1986). With
the exception of the TDCRP (Elkin et al. 1989), all these studies found that CBT was
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