Table of Contents

Cognitive Behaviour Therapy

Cognitive therapy

Cognitive therapy describes a group of psychological treatments which aim to bring about improvement in psychiatric disorders by altering maladative thinking.

Cognitive therapy developed as a reaction against the extreme approaches of behavioural treatment which denied the importance of the patient's thoughts and feelings. In part it developed from dissatisfaction with psychoanalytic methods of psychotherapy which concentrate on unconscious processes and past events to the exclusion of patients's current preoccupations and problems.

In the literature of cognitive therapy, the word cognition is often used in a special way which is more restrictive than its general use in psychology. The general meaning of cognition is "all forms of knowing, that is attending, perceiving, thinking and remembering".

It is expected that other improvements (e.g. in. mood and behaviour) will follow. Thus the aim of cognitive therapy differs from the aim of behaviour therapy in which changes in behaviour are brought about with the expectation that improvement in cognitions (and mood) will follow. The special feature of cognitive therapy is that cognitive change is the primary target; it is the change from which all other changes are expected to follow.

By what means is this change in cognitions to be brought about? Cognitive therapy uses an assemblage of cognitive techniques, that is of techniques in which abnormal thinking is changed by using verbal rather than behavioural techniques. Such verbal techniques include explanation, discussion, questioning of assumptions, and so on. Cognitive therapy also employs techniques which are behavioural: patients are required to carry out actions which are chosen because they are judged likely to change the way the person thinks. This"learning from experience" is an essential element in cognitive therapy, and it is for this reason that Beck prefers to speak of (Cognitive-behaviour therapy).

The origins of cognitive therapy

Cognitive therapy has two distinct but related origins. The first source of ideas is the work by Beck. Having undertaken psychoanalytic training Beck was used to treat many depressed patients with psychoanalysis or psychoanalytic psychotherapy. Because he was not satisfied with the results of this treatment, Beck began to study his patients in a different way, paying more attention to conscious mental processes than to the unconscious. Beck described a number of recurrent themes in the thinking of depressed patients and he made a novel suggestion. Instead of regarding these thoughts as indicators of a basic unconscious process or as symptoms of a biochemical disorder, Beck suggested that the abnormal thinking of depressed patients was the primary disorder, that is the disorder from which all the other features of the depressive syndrome originate. From these original ideas Beck developed an ingenious set of techniques for changing the thinking first of depressed patients and subsequently of anxiety disorders. It is possible to suppose that some or even all depressive cognitions may arise from an antecedent cause such as a biochemical disorder but that, once established, cognitions maintain depression; and that recovery will be accelerated if the cognitions are brought under control.

The second line of development of cognitive therapy can be traced back to a group of American psychologists who were dissatisfied with the extreme behavioural approaches to treatment. Among these psychologists, Meichenbaum studied the recurring thoughts of anxious people and sought a way of changing the thoughts. He observed the similarity between his findings and those of Ellis, the inventor of 'rational emotive therapy'. Meichenbaum developed his own techniques along broadly similar lines.

Others have taken up these ideas, developed them, and applied them to other disorders with the result that the two original strands of development are now closely interwoven.

Although still mainly used in the treatment of anxiety and depressive disorders, cognitive therapy is beginning to be used to treat disorders of eating and as a general approach to dealing with worry associated with life problems.

A classification of cognitive therapies

Cognitive techniques are divided into four groups according to their aims: techniques for interrupting repetitive cognitions, techniques for counterbalancing the emotional effects of cognitions, techniques for altering cognitions, and techniques for solving problems. Each will he discussed in turn:-

Techniques intended to interrupt Cognitions:

These are the simplest methods which merely aim to stop a sequence of intrusive thoughts in the hope that the thoughts will not start again immediately. Techniques of distraction may help in this way by forcing the patient to attend closely to something other than the intrusive thoughts. Attention may be focussed on another mental content, for example, by performing mental arithmetic; or on the immediate environment, for example, by counting objects of a particular kind.

Because intrusive thoughts are often difficult to interrupt in this way, another technique has been tried. This is "thought Stopping", a method originating in the treatment of obsessional thoughts- a form of abnormal thinking which is particularly difficult to arrest. In thought stopping a sudden, intense but short-lived distraction is arranged. The distraction can take many forms but two common forms are: (i) the patient first shouts aloud and after practice repeats silently to himself, the word "Stop" and (ii) a mildly painful sensation is produced, for example, by stretching and easing a rubber band encircling the wrist.

Techniques intended to counterbalance cognitions

Most intrusive cognitions provoke an emotional reaction, usually anxiety or depression but sometimes arousal or anger. Techniques in this section can he regarded as balancing the intrusive thought with another thought produced by conscious effort. For example, the anxious patient who, when his heart beats fast, thinks 'I am going to have a heart attack', could be trained to repeat to himself the thought that the fast beating is merely a normal and harmless bodily response to stress. These are called adaptive self-statements. Although attractively simple in principle, the techniques are difficult to practise. It is seldom enough to tell the patient to repeat a suitably chosen statement to himself, when the intrusive thoughts are present, most patients find it difficult to concentrate effectively on such a plan of action. Meichenbaum recommends a three-stage procedure. First the patient is helped to conceptualise his problem as one in which his thoughts are important but inaccurate. To help him do this, the patient may be asked to go into a stressful situation and record his thoughts, or alternatively to imagine a stressful situation vividly while speaking his thoughts to the therapist. In the second stage, the patient is encouraged to consider how his thoughts may he increasing his symptoms (in the previous example, thoughts about a heart attack increasing anxiety) or interfering with his efforts to cope with problems (e.g. thoughts that he is a failure).Only when these first two stages have been dealt thoroughly is the third stage introduced. In this stage the patient is helped to find appropriate alternative statements; statements are suitable if they are convincing to the patient when he is in a composed state of mind, and also brief and easy to recall.

Techniques intended to alter cognitions

This group of techniques is designed to alter attitudes and beliefs and thereby to eliminate or change intrusive cognitions. Several methods are used. The most fully developed of this group of treatments was devised by Beck. In the first stage of Beck's treatment patients are encouraged to identify maladaptive cognitions. In the second stage patients are helped to identify "logical errors' which allow these maladaptive cognitions to persist, to test them in behavioural experiments and thereby give up these ways of thinking. In the final stages of treatment, attention is given to chathe underlying assumption, which are thought to generate the maladaptive cognitions in the first place.

Techniques for solving problems

These techniques deal indirectly with the effects of life problems. Stressfulness of life problems depends on the unduly negative interpretations made by the patient. Techniques in this group help patients resolve stressful life problems directly. The basic intentions are to define the problem, divide it into manageable parts, think of alternative solutions, select the best solution, carry it out, and examine the result.

APPLICATION OF SPECIFIC METHODS OF COGNITIVE THERAPY

Depressive disorders

The cognitive disorder

The cognitive disorder in depressed patients was described clearly by Beck. He recorded the thoughts reported by 50 depressed patients receiving treatment either with psychoanalysis or psychoanalytic psychotherapy. Beck described two kinds of abnormality: repeated intrusive thoughts and 'cognitive distortions'. The intrusive thoughts were concerned with low self-regard, self-criticism and self-blame, ideas of deprivation, injunctions (e g 'I ought to do more for other people'), and the wish to escape or die. The cognitive distortions were ways of thinking that biased the patient's view of reality and made it possible for him to believe in the ideas represented in the intrusive thoughts. Beck has described four kinds of cognitive distortions: arbitrary inference, selective abstraction, over-generalisation and magnification/minimisation

Arbitrary inference was defined by Beck as 'the process of forming an interpretation of a situation, event or experience when there is no factual evidence to support the conclusion or when the conclusion is contrary to evidence'. For example, a person sees a friend in the street and the friend fails to acknowledge him; the person concludes that the friend no longer likes him. In this example the depressed person has failed to consider alternative explanations (for example, that his friend was preoccupied with personal worries and has not weighed the evidence for and against that he knows that his friend's child is ill in hospital).

Selective abstraction is 'the process of focussing on a detail taken out of context, ignoring other more salient features of the situation, and conceptualising the whole experience on the basis of this element'. For example, a person is with a large group of friends in a public house, and all but one greet him warmly, the patient focuses on this single failure to acknowledge him and concludes that he is a boring person. In this example, the depressed person fails to balance the evidence of a single rejection with the evidence of the many friendly greetings.

Over-generalisation is defined as 'drawing a general conclusion about ability, performance or worth on the basis of a single incident'. For example, a woman who spoils one of the dishes at a single family meal concludes that she is a bad mother. In this example the depressed person has evidence of failure in one small aspect of her role as a mother, but fails to take account of evidence of competence in all the other aspects.

Magnification or minimisation are errors in evaluation which are so gross as to constitute distortions. An example of magnification is provided by a person who makes a single unimportant error in his work and concludes that, should his employer discover the error he would be moved to a less responsible job. An example of minimisation is provided by a depressed person who although feeling unwell, makes a great effort to help a friend who is in trouble, and yet fails to accept this as evidence that he is doing his best.

Although Beck's categories are useful in helping patients to identify depressive styles of thinking, they are not mutually exclusive categories. The housewife who spoils one dish for the family meal can be said to have engaged in 'magnification' as well as in 'over-generalisation'; and the difference between the first two examples is mainly that in the second the person fails to give sufficient weight to the evidence acquired at the time, while in the first he fails to give sufficient weight to evidence acquired on previous occasions.

As well as these errors of logic, Beck also described, unrealistic Assumptions which add to the depressed person's tendency to develop low mood. These assumptions concern the relationship between life experience and psychological state: for example, that a person can only be happy if he is successful in his work, or if all the people he knows like him. Assumptions are likely to be related to previous experiences of the individual patient.

Beck summarised the cognitive disorder resulting from these errors as a cognitive triad, the three components being (a)a negative view of the self(b)negative interpretation of current experience and (c) negative view of the future. These ways 'of thinking will be immediately recognisable to most psychiatrists who have listened carefully to their depressed patients. There is also an increasing amount of research evidence to support Beck's clinical observations.

The changes mentioned so far are not the only cognitive changes among depressed patients. Two others are relevant to treatment: Hopelessness and helplessness and impaired responsiveness to positive reinforcement (The former is closely related to Beck's cognitive triad).

Depressed patients have attitudes of hopelessness (i.e. they do not expect to recover and do not think that other people can assist them) and Helplessness ( i.e. they do not think that they can do anything to help themselves). Although these attitudes are prominent features of the depressed person's thinking, they are not, of course, limited to depressive disorders. A possible origin for these attitudes has been suggested by the results of experimental studies of 'learned helplessness' by Seligman. Seligman's original experiments on learned helpless in animals showed the possible relation between repeated experiences in which aversive (painful) stimuli were given to an experimental animal in circumstances which allowed no possibility for any action that would terminate the stimuli or allow escape from them. Animals treated in this way ceased to take actions to protect themselves from unpleasant stimuli, not only in the original circumstances but generally. Seligman suggested that these experiments provided a parallel with the development of depressive disorders. His original formulation was revised to take account of the fact that depressed patients blame themselves, which they should not do if they can perceive no connection between their actions and the things that happen to them. This revised hypothesis states essentially that people become depressed when they can perceive no connection between their actions and the unpleasant events that happen to them, and they also attribute this lack of control to personal inadequacy. Whether or not this account of the origins of helplessness and hopelessness is correct, there is little doubt that these attitudes are held by many depressed patients and that they can be a major obstacle to progress in treatment since hopeless patients do not co-operate well. There is some experimental evidence to support these clinical observations, for example, the finding that, compared with normal subjects, depressed subjects are more likely to ascribe success in an experimental task to luck and to ascribe failure to personal inadequacy.

There is another important psychological change in depressed patients. Although there is no overall impairment of memory of the kind found in organic mental disorders, there is a memory change of a different kind. Depressive mood change, whether occurring as part of a depressive disorder or as normal sadness, is accompanied by greater accessibility of unhappy as compared with happy memories. Since thinking about depressive ideas leads to depressive mood, a circular process could follow in which depressive mood leads to the greater accessibility ol concepts which lead to negative interpretation of experience and thus to a more depressed mood.

If cognitions are be given a causal role in the onset of depressive disorders,it is necessary to assume that the 'maladaptive assumptions' found in depressed patients were present before the episode of depression began. Although there are practical difficulties in investigating the state of patients before the start of a depressive disorder, there is increasing evidence that the cognitive distortions found in depressed patients diminish markedly, and perhaps disappear, when the depression recovers. It is possible that the cognitive changes occurring in the early stages of a depressive disorder may initiate a vicious circle that can convert an otherwise mild and short-lived reaction into one that is more severe and prolonged.

Cognitive techniques used in the treatment of depressive disorders

Cognitive techniques for depressive disorders are generally intended to alter Cognitions and not merely to arrest or counterbalance them. These methods are used because depressive thoughts are very difficult to arrest and evoke a particularly strong emotional reaction which is difficult to counteract.

The techniques used are generally those devised by Beck. They are combined in a complicated way that can only be learnt adequately by supervised experience, so that the following account can only serve as a general guide to some of the major features of the treatment.

ACTIVITY SCHEDULES

Depressive patients are often apathetic and inactive and, they derive less pleasure than usual from activities that they normally enjoy The more depressed the patient, the more use is made of techniques to counter these abnormalities before embarking on ways of changing cognitions. These schedules of 'graduated activities should (i) encourage everyday routines such as small household tasks and hobbies requiring little intellectual ability (e.g. simple carpentry or gardening); and (ii) arrange small pleasures, such as walking with a pet dog, or eating a favourite dish.

IDENTIFYING DEPRESSIVE THOUGHTS

The next stage of treatment is to help the patient identify recurring intrusive thoughts that increase depressed mood. This is done by keeping written records of moods and thinking in everyday life, and by describing thoughts experienced during interviews with the therapist. Role play is another technique which can help to elicit depressive thoughts if the other two are not productive.

ANSWERING NEGATIVE THOUGHTS

Several techniques are used to alter cognitions. First, the patient is encouraged to examine the evidence for and against his ideas and beliefs, and in doing so to become aware of and correct the logical errors which allowed him to arrive at and sustain these ideas and beliefs. This is usually done most effectively if the therapist restricts his role to that of asking questions and reminding the patient of relevant evidence, and refrains from providing ready-made explanations. As well as testing assumptions verbally in this way, it is important that patients should also test them through experience. To do this, 'behavioural tasks' are arranged between the interviews and the outcome of each assignment is reviewed during the next session with the therapist. There is a strong impression that without these behavioural tasks, treatment is less effective. Having established the illogical nature of the patient's beliefs and attitudes, the next step is to help him work out alternatives.

PROBLEM SOLVING

Although this is not the major focus of cognitive therapy for depression, patients may need some help in working out solutions to persistent life problems which are helping to maintain their disorder.

The effectiveness of cognitive therapy for depressive disorders

Several studies have compared the effects of cognitive therapy and antidepressant drugs in depressed patients. The first was by Beck and his colleagues who compared cognitive therapy with imipramine (an a tricyclic antidepressant) given in adequate dosage to 41 out-patients, meeting criteria for 'definite' depression, and having a minimum score of 20 on the Beck Depression Inventory. Patients requiring admission to hospital were excluded from the study, as were patients with a history of a poor response to adequate treatment with a tricyclic antidepressant. Both groups improved and the cognitive therapy group improved significantly more than the antidepressant group. (It should be noted, however, that antidepressant treatment was stopped two weeks before the assessment at the end of treatment.) At follow-up 6 months later patients who had completed cognitive therapy were still significantly better than the others on measures of symptoms. More patients dropped out from drug treatment than from cognitive therapy, but the main results were the same whether or not these dropouts were included in the analysis. When followed up after 12 months, the cognitive therapy group had significantly lower scores on the Beck Depression Inventory (less depressed).

These surprising findings were broadly confirmed in other studies though the results were not as straightforward as those of Beck. However, cognitive therapy was found to produce as much improvement as drug treatment while the combined treatment produced better results on some but not all measures of depression.

With the general practice patients in another study, cognitive therapy produced results that were not only as good as, but actually strikingly better than, those of drug treatment. The combined treatment group changed as much as the group receiving cognitive therapy. This part of the results is difficult to interpret because the amount of change in the drug treatment group was surprisingly small, suggesting the possibility (acknowledged by the authors) that the patients treated in general practice were not taking their drugs regularly.

In a further study with 87 depressed outpatients meeting criteria for primary unipolar depressive disorder, cognitive therapy led to as much improvement as the antidepressant drug. Because there was no placebo-only group, it is not certain that the improvement was not due to spontaneous recovery. However, the severity of the disorder makes this unlikely.

Taken together, these studies provide quite strong evidence that cognitive therapy produces improvement in depressive disorders of moderate severity, comparable to that produced by adequate doses of antidepressant medication. However, none of the investigations establish that the effect is specific.

There is another reason for suggesting that the effects of cognitive therapy on depressive disorders may not be due to a specific effect on cognitions. Two other psychological treatments have been shown to produce improvement in depressive disorders comparable to that produced by drugs. These other treatments are interpersonal therapy and behavioural therapy. Interpersonal therapy is a form of counselling directed to the problems in social relationships. It is assumed that the depressed mood results from these relationship difficulties which are of four kinds: loss, disputes about roles (husband and wife), role transitions (e.g: becoming a mother; being divorced); and lack of close relationships. For each of these relationship difficulties, a form of treatment has been devised, each form being concerned with present circumstances rather than with the past experiences that led up to these difficulties. Treatment is concerned with identifying problems in relationships, focussing on the part played by the patient's own behaviour and attitudes, and considering alternative ways of behaving and thinking.

Interpersonal Therapy has been tested in two clinical trials with depressed patients. In the first trial it was used as a 'continuation' treatment for depressed patients who had already been treated successfully with amitriptyline. Interpersonal treatment was compared with supportive interviews. After a year patients receiving interpersonal therapy had better social functioning than those receiving support, but they were no less likely to have been depressed. However, in a second trial of interpersonal therapy tested as a treatment for acute episodes of depression, positive rewere obtained. In this trial interpersonal therapy was compared with amitriptyline, a combinaof the two treatments, and a minimal treatment consisting of supportive interviews on demand. The interpersonal therapy group improved as much as the amitriptyline group and significantly more than the group receiving minimal treatment. The combined treatment gave somewhat -but not significantly- better results than either alone.

There is evidence that behavioural treatment for depressive disorders has a comparable effect. This treatment is based on the assumption that depressed patients lack positive reinforcement and experience excessive negative reinforcement, especially social reinforcement. Treatment is intended to improve social interactions of a kind that will yield more positive reinforcement, usually by a combination of assertive training and social skills training. Several trials have been reported although most have been concerned with depressed volunteers rather than patients' seeking treatment in the usual way. In these trials behavioural treatment was found to be superior to counselling, a group psychotherapy, individual psychotherapy, or amitriptyline. A study compared cognitive and behavioural treatments for depression, and found effects that were equal (and greater than the changes observed in a no-treatment control group).

The finding that interpersonal therapy and behavioural treatment produce changes at least as great as those of amitriptyline, indicates that the parallel findings with cognitive therapy should not be ascribed too readily to a specific effect on cognitions. Instead it seems possible that improvement during these three different psychological treatments is brought about by factors which they share. It is not possible to be certain what these factors are but three obvious candidates are a structured approach in which problems are dealt with one by one; graduated rewarding activities; and the reawakening of hope in recovery.

Value in clinical practice

The research findings reviewed in the previous section have drawn attention to important questions about the role of psychological factors in 'the maintenance of depressive disorders, some of which probably have a 'biological' cause. Nevertheless, these findings do not suggest any clear reasons for preferring cognitive therapy to drugs in everyday clinical practice. Cognitive therapy appears to be about as effective as amitriptyline in moderately depressed patients; at best it may be slightly more effective. Also, although the addition of cognitive therapy to drug treatment may speed recovery, the effect is not so great that it justifies its routine use in view of the substantial amount of additional treatment and the special training required to give this treatment. Cognitive therapy would, of course, be particularly useful if it were shown to be effective for patients who fail to respond to drugs. This has not been demonstrated to date, but it is an obvious next problem for research. Cognitive therapy would also be of value in everyday practice if it were shown to prevent relapse. At present there is no definite evidence that it does so.

Nevertheless, most clinicians can learn much about the psychological aspects of depressive disorder by reading accounts of cognitive therapy. Whatever the final assessment of the therapeutic value of cognitive treatment, this greater understanding of patients' experience is a valuable by-product of work of cognitive therapy.

Other uses of cognitive therapy

Cognitive procedures are designed to deal with the cognitive disorder found in a particular clinical syndrome- anxiety neurosis, depressive disorder, or eating disorder. Another group of cognitive procedures are intended to be used more generally. They deal not with the abnormal psychological reaction itself but with the person's way of coping with stressful events that may have caused the reaction. These so-called (problem solving methods) depend on a basic simple approach. The person is encouraged to define his problem more clearly, and if necessary break it down into a series of more manageable sub-problems. Alternative methods of solving the problem (or sub-problems) are then worked out and the merits and disadvantages of each solution are considered. One solution is chosen and a plan of action is made, breaking down when required actions into stages. These actions are embarked on one by one with careful assessment of progress. The value of each tactic is considered, not only as a way of solving the problem in hand but also as a more general approach that might be used on some future occasion. Considerable emphasis is placed on this last point with the hope that the person will learn not only how to reduce his present difficulties but also how to cope better with problems in the future.

This approach has been used quite widely, for example, with problems involving loss such as bereavement divorce or redundancy at work. It has also been used for the problems of alcoholic patients.

There is another group of procedures which can be applied to a variety of behaviours. These are generally considered to be separate from cognitive therapy. These self-control procedures are based on the hypothesis that in order to control his own behaviour a person needs to complete a three-stage process consisting of self-monitoring, self-reward and self-evaluation. In other words, the person must be aware of the behaviour and of the circumstances in which it takes place. He must provide himself with some form of positive (or negative) reinforcement which can maintain or reduce the behaviour. He must be aware of the effect of this reinforcement on the behaviour. It is suggested that behaviour, which is outside the person's immediate control (including some of the behaviour that forms part of mental disorders), continues because of a failure at one of these stages.

Treatment then becomes a matter of examining each stage and attempting to make it more effective. Self-monitoring is increased by encouraging the patient to keep records of the behaviour in question. This may be a behaviour whose frequency is to be reduced (e.g. smoking cigarettes; eating excessively) or a behaviour whose frequency is to be increased. Having identified the behaviour, the patient is encouraged to provide himself with an immediate reward (which may be a small treat) or verbal (unspoken). Whether the desired changes have been achieved, and seeking the reasons for any lack of success. Alone, these methods have rather limited application to clinical problems, the main one being to obesity. The principal use in clinical practice is as an adjunct to behavioural treatment.

The success in cognitive therapy in treating a range of depressive disorders and in reducing the risk of relapse((Blackburn et al. 1987; Simons et al. 1986)) has encouraged its application to clinical problems other than depression, This wider application is consistent with the cognitive model which, from the outset, was not intended to be confined to depression, but was applied 10 other behavioural and emotional disorders((Beck 1976, Beck et al 1985)). Many situations, people are subject to external event or bodily symptoms in which differences in cognitive interpretations lead to different patients and Intensity of affect and behaviour.

The extension of any therapeutic practice to a new problem area has to be taken in stages. Success in cases is treating single to other behavioural and emotional disorders((Beck 1976, Beck et al 1985)). In many situations, people are subject to external events or bodily symptoms in which differences in cognitive interpretations lead to different patterns and intensity of affect and behaviour.

The extension of any therapeutic practice to a new problem area has to be taken in stages. Success in treating single cases is at, essential first step It allows us to say that a therapeutic strategy can sometimes work with this problem area. The addition of more single cases will, if they also respond well, add plausibility to the claim that initial successes were not merely chance results.

This is how all new therapy applications have had to start The efficacy of a therapy for a certain client group will ultimately be judged by a full outcome study in which a large number of similarly diagnosed patients arc randomly assigned to groups, carefully assessed, and compared to patients in control conditions_ But outcome studies are very expensive in time and money and cannot therefore ratified until there is a good prima facie case that a treatment will work.

The different problem areas discussed in the chapters in this book all broadly come into this initial stage, where the plausibility of applying cognitive therapy to new client groups is examined. We believe strongly that the cognitive model is relevant to these disorders and we need to listen carefully to experienced cognitive therapists to learn which aspects of cognitive therapy they have found most helpful.

The result is a volume containing examples of how cognitive therapists working in different settings with different groups of adult clients have applied the cognitive model in their domain.

There is a need for careful analysis of the thoughts and images associated with the specific situation in which the offence has taken place, similar to the careful analysis which is done for clients with eating disorders and addictive behaviours. The cognitions thus elicited are the 'raw material' for cognitive therapy. Cole shows how they can be used to formulate hypotheses, conceptualise the case, decide on the need for therapy, and determine which technique will be most appropriate. She uses imagery to elicit thoughts associated with offence situations, showing how it reveals a wide range of interpretation by the clients of their own feelings and of other people's attitudes and reactions. Thus offenders have beliefs such as 'Women wear tight jeans to turn men on' or 'The woman who pays attention when I expose myself is showing how it excites her.

Cognitive therapy of depression ((Beck et al., 1979)) was described as a method of treatment for out-patients with mild to moderate depressions. All published controlled studies of efficacy have so far included only out-patients, usually satisfying research diagnostic criteria for major or definite depression ((Spitzer et al., 1978, Ferglaner et al, 1972)), unipolar subtype.

Seven studies have compared CBT with antidepressant medication, each alone or in combination ((Rush et al. 1977; Beck et al. 1979, Blackburn et al. 1981; Rush and Watkins 1981; Murphy et al. 1984; Teasdale et al. 1984; Beck et al. 1985)). The results of these treatment trials have all confirmed the efficacy of CT in the treatment of depression, CT being found equivalent or superior to antidepressant medication Other studies have compared CT with behaviour therapy in the treatment of depressed self-referred students and media-recruited depressed individual, These studies ((Shaw 1977, Taylor and Marshall 1977, Zeiss et /. 1979, Wilson et 1. 1983)) have found CT superior or equivalent to behaviour therapy and superior to waiting-list.

Various other studies ((Shipley and Fair, 1973)) have used behaviour therapy with strong cognitive component in depressed out-patients or depressed students, and found cognitive behaviour therapy to be an effective treatment, superior to psychodynamic or supportive psychotherapy.

Thus, the efficacy of CT, as described by Beck, or of other types of short-term therapies which are primarily cognitive in orientation, has been relatively well established in the treatment of depressed out-patients.

Thus, the efficacy of CT, as described by Beck, or of other types of short-term therapies which are primarily cognitive in orientation, has been relatively well established in the treatment of depressed out-patients. Questions which are often posed are: 'How effective is the same treatment method in the more severely depressed in-patients" and 'Can cognitive therapy be applied to in-patients?' There are, unfortunately, no published studies to date which could begin to answer these questions, but they are undoubtedly important practical questions. In this chapter, I will discuss some of the problems involved in the treatment of severely depressed in-patients and describe a case study as illustration.

Cognitive therapy with inpatients

Why do therapy with inpatients?

Since the majority of depressed patients in Britain are treated primarily by their general practitioners and- secondly, as outpatients in psychiatric clinics((Goldberg and Huxley 1980)), depressed patients who become in-patients have specific characteristics which distinguish them from the majority of depressed patients. In general, depressed patients who become inpatients in the National Health Service may have on or suicidal of the following characteristics: psychotic features, that is delusions and hallucinations: high suicidal risk, severe impairment with gross retardation or agitation, anorexia, and sleep disturbance, the need for electroconvulsive therapy (ECT) because of past history of response to ECT.

characteristics which distinguish them from the majority of depressed patients. In general, depressed patients who become in-patients in the National Health Service may have one or several of the following characteristics: psychotic features, that is delusions and hallucinations: high suicidal risk and/or suicidal behaviour, severe impairment with gross retardation or agitation, anorexia, and sleep disturbance, the need for electroconvulsive therapy (ECT) because of past history of response to ECT or because of current severity of illness, failure to respond to out-patient treatment and long duration of index episode of illness

Severely depressed in-patients are almost invariably treated by physical methods of treatment, medication, and/or ECT, with little or no psychotherapeutic input There are, however, several arguments for the usefulness of a psychotherapeutic approach such as CT m these patients because of, rather than in spite of, Depressed in-patients may often exhibit hopelessness regarding their prospect for improvement They are likely to have been depressed for a have, long time and to have already been treated with two or three different antidepressant drugs, They may be naturally, become sceptical about outcome of further treatment CT offers an alternative approach which has face validity and may revive some hope in treatment in general.

CT techniques can also be used to increase compliance with drug regimens when a combined treatment is being considered.

  1. The long months of illness or the recurrent nature of the illness, in addition to fostering hopelessness, also creates a sense of lack of control which is increased by the medicalisation of the illness. The patient may often voice the implicit message given to the physician: `Something is wrong with my biochemistry—there is nothing I can do about it.' By its methodology which stress, coping techniques and empirical verification, CT increases a sense of control which is in itself beneficial A problem may aria, about the apparent double or inconsistent message loch is being given to the patient when he is receiving both CT and pharmacotherapy

SEVERELY DEPRESSED PATIENTS

These are for each individual. Sometimes, medication alone can help, but sometimes we find that combining medication with a therapy that helps people to work on their problems can be more helpful. Both treatments are equally important and work together. Let me tell you about cognitive therapy_..' And again the usual explanation and socialisation would then ensue. The following case study will try and elucidate these points further, as well as describe the course of therapy.

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