Determinants of change in cognitive therapy for depression

We explored the processes of change in cognitive therapy of depression in a sample of 25 adult outpatients. Raters blind to treatment outcome listened to audiotapes of sessions and rated items that pertained to (a) the therapist-offered facilitative conditions (warmth, empathy, etc.); (b) the patient—therapist relationship (the helping alliance); and (c) the therapist's adherence to the methods of cognitive therapy. Adherence separated into two factors in a factor analysis. One factor, representing concrete, symptom-focused methods of cognitive therapy, predicted subsequent symptom reduction when assessed early in treatment, but not later. The other factor, representing less focused, more abstract discussions, did not predict improvement. Neither did facilitative conditions nor the helping alliance predict change that occurred after the rated session. However, later in treatment, the helping alliance was predicted by prior symptom reduction. Methods used to discern the temporal relations of in-session behavior to outcome are highlighted.We wish to thank Aaron T. Beck and the therapists, staff, and patients at the Center for Cognitive Therapy, without whose cooperation this project would not have been possible.Portions of this paper were presented at the 21st Annual AABT Convention, Boston, November 1987, and at the 19th annual meeting of the Society for Psychotherapy Research, Santa Fe, New Mexico, June 1988.This research was supported in part by a grant from the Biomedical Research Foundation of the University of Pennsylvania, and by the Foundation for Cognitive Therapy and Research.     

Immediate effects on depression of cognitive therapy interventions

The immediate effects on depression of exploring versus modifying depressive thoughts were compared in chronic moderately to severely depressed patients receiving cognitive behavioral therapy (CBT). Using a withinsubject design, it was found that periods of cognitive CBT consistently produced more change in belief in identified depressive thoughts than did similar periods devoted to exploring and obtaining more information relevant to the thoughts. The greater change in belief resulting from cognitive CBT was consistently accompanied by greater reduction in self-rated depressed mood than was obtained in the Thought Exploration condition. Differences in the effects of the two conditions on a measure of speech rate were not consistent. The results support a central prediction of the cognitive model of depression and suggest the specific therapeutic effectiveness of cognitive CBT techniques.This research was supported by the Medical Research Council of the United Kingdom. We are grateful to Peter Amies and Gillian Butler, who rated the recordings of the treatment interventions.     

"White coat effect" induced by therapist's presence during speech therapy for stroke rehabilitation: a single case study

The excessive pressor response triggered in patients by an alerting reaction to a doctor's presence has been termed the "white coat effect." A 68-year-old man with verbal apraxia after multiple lacunar infarctions was referred to the hospital for speech rehabilitation. He experienced difficulty in talking with the speech therapist during therapy sessions but not when talking with his friends or family. Because the therapist's presence was stressful to the patient, it was considered that his anxiety might produce an excessive increase in blood pressure. Blood pressure monitoring was performed during 2 separate days of speech therapies consisting of two sessions each. In one session, therapy was directed by the therapist; in the other, therapy was self-directed. The therapist-directed approach substantially increased both systolic and diastolic blood pressures, whereas the self-directed therapy slightly increased only systolic pressure. It was concluded that the excessive pressor response seen in this patient during therapist-directed speech therapy resulted from the white coat effect induced by the therapist's presence.     

Fostering Cognitive Change in Cognitive Therapy of Depression: An Investigation of Therapeutic Strategies

There is little evidence regarding which therapist strategies promote cognitive change in cognitive therapy (CT) of depression. Drawing from a sample of CT patients, we selected two consecutive sessions for which patients reported markedly different amounts of cognitive change (CC; i.e., a low and high cognitive change session). We then investigated whether four observer-rated psychotherapy process variables differentiated high and low CC sessions. Our analyses focused on 62 patients with large session-to-session differences in self-reported CC. Results from single predictor models showed the therapeutic alliance and therapists’ use of cognitive methods predicted high versus low CC session type. In a model including multiple predictors, only cognitive methods remained significant. These findings are consistent with the view that cognitive methods promote CC in CT.

     

A Multi-wave Web-based Evaluation of Cognitive Content Specificity for Depression,Anxiety, and Anger

This study tested the cognitive content specificity hypothesis of Beck’s cognitive theory using a web based report of mood and cognitions for that day completed once a week for 5 weeks. The use of a multi-wave design and structural equation modeling allowed for the separation of occasion-specific variability from over-time stability, thereby increasing sensitivity to the relatively brief changes in negative affect typical of student populations. To further increase specificity, an expanded set of cognitive themes was tested for depression, anxiety, and anger. Consistent with models indicating that these mood states share a general negative mood, all cognitions had a significant non-specific relationship to all three mood states. For tests of occasion-specific cognitive content specificity, thoughts of Transgression were incrementally specific to angry mood whereas Defectiveness, Hopelessness, and Abandonment were each specific to depressed mood. Failure was more strongly related to depression and anxiety than anger. Contrary to hypotheses, both Dependence and Vulnerability to Harm were non-specific only.

The development of an adaptive upper-limb stroke rehabilitation robotic system

Background

Stroke is the primary cause of adult disability. To support this large population in recovery, robotic technologies are being developed to assist in the delivery of rehabilitation. This paper presents an automated system for a rehabilitation robotic device that guides stroke patients through an upper-limb reaching task. The system uses a decision theoretic model (a partially observable Markov decision process, or POMDP) as its primary engine for decision making. The POMDP allows the system to automatically modify exercise parameters to account for the specific needs and abilities of different individuals, and to use these parameters to take appropriate decisions about stroke rehabilitation exercises.

Methods

The performance of the system was evaluated by comparing the decisions made by the system with those of a human therapist. A single patient participant was paired up with a therapist participant for the duration of the study, for a total of six sessions. Each session was an hour long and occurred three times a week for two weeks. During each session, three steps were followed: (A) after the system made a decision, the therapist either agreed or disagreed with the decision made; (B) the researcher had the device execute the decision made by the therapist; (C) the patient then performed the reaching exercise. These parts were repeated in the order of A-B-C until the end of the session. Qualitative and quantitative question were asked at the end of each session and at the completion of the study for both participants.

Results

Overall, the therapist agreed with the system decisions approximately 65% of the time. In general, the therapist thought the system decisions were believable and could envision this system being used in both a clinical and home setting. The patient was satisfied with the system and would use this system as his/her primary method of rehabilitation.

Conclusions

The data collected in this study can only be used to provide insight into the performance of the system since the sample size was limited. The next stage for this project is to test the system with a larger sample size to obtain significant results.

     

Self-Understanding, Empathy, Guided Discovery, and Schema Belief in Schema-Focused Cognitive Therapy of Personality Problems: A Process–Outcome Study

The aim of this study was to examine the dispositional and/or episodic influences of the process variables of self-understanding, empathy, guided discovery, and convictions about primary early maladaptive schema, which are central concepts in the schema-focused cognitive therapy of personality problems. The sample consisted of 35 patients with panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits who participated in an 11-week inpatient program. Patients, therapists, and an expert observer rated individual therapy sessions. Greater patient-rated self-understanding the first session was related to greater decreases in schema belief and of emotional distress throughout therapy. Greater therapist-rated empathic experience the first session was related to greater decreases in distress throughout therapy. Session-by-session analyses revealed few sequential relationships. However, a greater in-session reduction of schema belief weakly predicted lower level of presessional distress the next session, and vice versa. The study illustrates how to intensively measure and model change in psychotherapy, using both growth curve and time series analyses.     

A nursing experience of cognitive therapy with a major depression patient

The increasing number of major depressive patients with negative thinking warrants that cognitive therapy be recommended to correct negative-automatic thinking and inculcate positive thinking as a way to face problems. The purpose of this paper was to describe the nursing experience and effectiveness of implementing individual cognitive therapy on a patient with major depression in an acute ward over a one-month period. Through observation, interviewing, and comprehensive nursing assessment, the patient's negative thinking toward herself and her problems was identified, and her thoughts of suicide emerged. The following three major health problems were identified: risk of suicide, disturbed sleep pattern and ineffective coping. The patient underwent homework training throughout the ten individual cognitive therapy sessions, and was expected to use positive thinking instead of automatic thinking. After the intervention, the patient's depressive mood, sleep quality, and coping ability were improved. In addition, the patient no longer talked of suicide and was able to show stable emotions, maintain a homework, and attend church activities on her own initiative after discharge. It is therefore, suggested that cognitive therapy can be an effective intervention for nurses planning to care for this group of people.     

Articulated thoughts,irrational beliefs,and fear of negative evaluation

Contemporary cognitive behavioral theories of psychopathology and therapy assume that people's emotional and behavioral problems are influenced by particular patterns of thought. And yet there is little direct evidence in support of this widespread belief. An experiment is reported that examined the thoughts of people high or low on measures of social-evaluative anxiety and of the tendency to think irrationally. Subjects' cognition was studied under controlled laboratory conditions in the articulated thoughts during simulated situations paradigm, in which the subject role-played an audiotaped interpersonal encounter and, at predetermined points, verbalized thoughts elicited by a short segment of the fictitious event. Several findings emerged: Subjects thought less rationally when confronted with stressful situations than with a nonstressful one; subjects high on questionnaire-defined fear of negative evaluation and irrational thinking rated stressful tapes as more anxietyprovoking than did subjects low on these inventories; for highly fearful and irrational subjects, self-reported global anxiety elicited by stressful tapes correlated significantly with irrationality detected in their articulated thoughts. Irrational thinking as measured by articulated thoughts, however, did not correlate with inventories that are expected to predict irrationality in specific situations.This research was supported by NIMH grant MH 24237. Thanks go to Keith Edwards for useful discussions.     

Cognitive Change Across Cognitive-Behavioral and Light Therapy Treatments for Seasonal Affective Disorder: What Accounts for Clinical Status the Next Winter?

Efficacious treatments for seasonal affective disorder include light therapy and a seasonal affective disorder-tailored form of cognitive-behavioral therapy. Using data from a parent clinical trial, these secondary analyses examined the relationship between cognitive change over treatment with cognitive-behavioral therapy, light therapy, or combination treatment and mood outcomes the next winter. Sixty-nine participants were randomly assigned to 6-weeks of cognitive-behavioral therapy, light therapy, or combination treatment. Cognitive constructs (i.e., dysfunctional attitudes, negative automatic thoughts, and rumination) were assessed at pre- and post-treatment. Dysfunctional attitudes, negative automatic thoughts, and rumination improved over acute treatment, regardless of modality; however, in participants randomized to solo cognitive-behavioral therapy, a greater degree of improvement in dysfunctional attitudes and automatic thoughts was uniquely associated with less severe depressive symptoms the next winter. Change in maladaptive thoughts during acute treatment appears mechanistic of solo cognitive-behavioral therapy’s enduring effects the next winter, but is simply a consequence of diminished depression in light therapy and combination treatment.     

Exploring the listening experiences during guided imagery and music therapy of outpatients with depression

The purpose of this preliminary study was to explore the listening experiences of outpatient depression sufferers who underwent guided imagery and music therapy (GIM). A purposive sampling method was performed at the psychiatric outpatient clinic of a medical center in southern Taiwan from April 2003 to June 2004. The five subjects in this study all underwent a total of eight sessions of individual GIM therapy. The researcher invited a therapist to implement the GIM therapy sessions. Researchers conducted a semi-structured, in-depth telephone interview with each subject within 24 to 48 hours after each therapy session. Eight interviews were accomplished and transcribed for each case, and then subject to content analysis. The results showed a total of 55 important listening episodes, which could be categorized into the following 5 themes: (1) leisurely wandering in very natural sceneries; (2) creation of surreal virtual surroundings; (3) recollection of past life experiences; (4) submersion in thematic music melodies; and (5) experiencing various physical relaxation events. The triggering effect represented a combination of multiple factors, including music, the individual, the therapist and environment. The theme of each patient's imagery episode was a result of the effect of the four factors, with music having the greatest impact. This study hopes to present the listening experiences of depression sufferers in GIM therapy; to make suggestions for future investigations into subsequent impacts and changes that GIM has on patients; and to, perhaps, serve as references for future clinical practice or studies.     

The cognitive content of anxiety: Naturalistic evidence for the predominance of threat-related thoughts

Beck's (1976) hypothesis that the experience of anxiety is preceded by thoughts with a content of personal threat or danger was evaluated in a study that controlled for effects due to experimenter expectancy. Seventy introductory psychology students were exposed to one of three types of expectancy training: One group was trained to expect threat-related thoughts prior to experiencing anxiety, another group was trained to expect loss-related thoughts, and the final group received a neutral training. Subjects were then asked to record their thoughts preceding anxiety experiences in a free-response journal format. Each response was categorized as either a thought of threat, thought of loss, or other thought, and the number of thoughts falling into each category was the dependent variable. Threat was found to be the predominant cognitive content across groups (p < .001), while training had a small but significant (p < .05)effect on subjects' responses. These results are seen as offering qualified support to Beck's proposed threat-anxiety connection. This article is based on an M.A. thesis by the first author, who was supported during much of its preparation by U. S. Public Health Service Traineeship 5T01MH08929-12. The authors would like to thank George Allen and Charles Lowe for their helpful comments on the research, and Laurie Heatherington, William Matthews, and Eleanor Wertheim for scoring the free-response data.     

Aerobic exercise and cognitive therapy in the treatment of dysphoric moods

This study examined the separate and combined effects of verbal (cognitive) therapy and aerobic exercise for the treatment of individuals experiencing difficulties coping with dysphoric moods. Sixty-one volunteers who scored between 9 and 30 on the Beck Depression Inventory were randomly assigned to one of three conditions: running only, cognitive therapy only, or combined running and therapy. Cognitive therapy was provided in 10 weekly individual sessions, while supervised running was conducted in small groups three times a week for 10 weeks. All three treatment conditions produced significant but not differential improvement over time on measures assessing a variety of mood states. Posthoc analyses demonstrated that all treatments were equally effective for individuals who initially would have been considered to be mildly depressed (BDI < 20) and those who would have been considered moderately depressed (BDI 20). Four-month follow-up data indicated that the improvement had been maintained. The correlation between improvement on depression scores and an index of improved physiological functioning was not significant. Thus, the mechanism through which exercise influences mood was not clarified. These results suggest that supervised involvement in aerobic exercise may be a viable and cost-efficient alternative treatment to traditional individual verbal therapy for some individuals experiencing difficulty with dysphoric moods.This article is based on Jeffrey Fremont's doctoral dissertation, which was conducted under the supervision of Linda W. Craighead at The Pennsylvania State University.     

The Driver's Angry Thoughts Questionnaire: A Measure of Angry Cognitions When Driving

Five forms of driving-related angry cognitions were identified—Judgmental/Disbelieving Thinking ( = .94), Pejorative Labeling/Verbally Aggressive Thinking ( = .92), Revenge/Retaliatory Thinking ( = .93), Physically Aggressive Thinking ( = .93), and Coping Self-instruction ( = .83). Pejorative labeling/verbally aggressive, physically aggressive, and revengeful/retaliatory thinking correlated positively with each other and with driving anger, aggressive driving anger expression, aggression, and risky driving behavior. Coping self-instruction tended to correlate negatively with these variables. Judgmental/disbelieving thinking correlated positively with other forms of angry thinking, but was only somewhat correlated with other variables. Driving-related angry thoughts, except coping self-instruction, correlated positively with general hostile automatic thoughts. Differences in strengths of correlations with specific variables, and contributions to regression analyses supported the discriminant and incremental validity of driving-related angry thoughts. Implications for cognitive processes in anger and interventions were discussed.     

Cognitive Modification versus Therapeutic Support for Internalizing Distress and Positive Thinking: A Randomized Technique Evaluation Trial

It is important to evaluate not only comprehensive treatment packages, but also specific procedures to determine their contribution to the change process. The current study examined the efficacy of cognitive modification (CM) techniques compared to supportive therapy (ST) for university students reporting significant internalizing distress. CM consisted of three sessions of Fluency Training (FT) to increase positive self-statements and three sessions of Thought Record (TR) training in challenging negative thoughts. Participants (N = 57) were randomized to CM or ST and assessed at pre-, mid-, post-treatment, 1- and 3-month follow-ups. Intent-to-treat analyses suggested that CM produced greater changes in internalizing distress and positive thinking, which was especially apparent at midtreatment with small-to-medium differences consistently favoring CM at post-treatment and follow-up. These data suggest that change in CM was beyond that attributable to time spent with an engaged therapist who provided a treatment rationale, subsequent intervention and homework assignment.     

Clients' perceptions of therapeutic helpfulness in cognitive and marital therapy for depression

Twenty women who received marital therapy and 11 women who received cognitive therapy for co-occurring depression and marital discord reported the most helpful aspects of therapy. The verbatim responses of clients were coded into 12 response categories, and the responses of clients in the two therapies were compared to assess whether they reported similar or different therapy factors as most helpful. Clients who received marital therapy reported that the most helpful aspects of therapy were relationship-focused or interpersonal, while clients who received cognitive therapy reported that the most helpful elements were intrapersonal. The client reports are discussed in relation to independent ratings of therapist behavior and the intended impact of the treatments.This research was supported in part by NIMH grant MH 38390. We thank Lawrence P. Riso for his aid in category assignment and Michele Cascardi, Jennifer Christian, and Lloyd Goldsamt for their judgments of therapist behaviors. Dr. Steven Beach and Dr. Evelyn Sandeen coordinated various aspects of the overall research project from which these data were obtained. We are grateful to Susan O'Leary for her editorial feedback.