• Able to identify a clear precipitating event for the depressive episode • Have close relationships with others The initial sessions of CBT focus on establishing the therapeutic relationship, defining the problem with the client, and outlining the CBT treatment process (Gautam et al., 2020). If the therapist and client have many of the qualities outlined previously, there is a high likelihood of developing a rapport and an alliance that is conducive to effective therapy. The therapist can promote a sense of trust and safety with the client, which will help enhance progress. When defining the problem with the client, the therapist
asks a series of questions designed to clarify the issues of difficulty as the client sees them; through this process, the therapist can determine the maladaptive schemas the client uses to handle difficulties (Gautam et al., 2020). Over the course of therapy, the clinician helps clients to understand their particular maladaptive schemas, the ways these schemas lead to maladaptive coping strategies, and how these strategies play a role in perpetuating depression. The therapist can use various behavioral techniques to help the clients shift their distorted thinking and develop better coping strategies (Chand et al., 2023; Hawley et al., 2016). Table 6 provides an outline of some behavioral techniques, their descriptions, and examples of their use.
Table 6: CBT Behavioral Techniques, Descriptions, and Purpose Behavioral Technique Description
Purpose
Scheduling activities
The client records daily activities, hour by hour, then rates each completed activity on a scale from 1 to 10 for mastery of the activity and level of pleasure. The therapist asks the client to imagine each step that the client needs to take in order to accomplish a particular task.
This technique helps clients gain a sense of accomplishment and recognition that pleasurable activities are possible. This technique helps the client prepare mentally in order to focus on a particular task and identify obstacles that may interfere with positive interactions with others. This technique can be used as a tool for the therapist to identify a client’s negative thoughts that undermine achievement and to help the client practice new, adaptive thinking. A client can learn to see the behavior from an objective point of view and may be stimulated to find alternative ideas about how to behave.
Cognitive rehearsal
Role-playing
The client practices dealing with difficult situations using the therapist as a proxy.
Role reversal
A reversal of the role-playing technique: The therapist assumes the role of the client and encourages the client to reflect on how other people view the behavior. The therapist helps the client recognize a distressing thought or negative response and reduce its impact by focusing on something else.
Distraction
This technique teaches the client how to reduce the intensity of painful thoughts and feelings.
A key feature of using CBT techniques is to interrupt clients’ distorted thinking patterns that lead to depressive episodes (Chand et al., 2023; Gautam et al., 2020). Many clients who have maladaptive schemas and associated coping strategies are so accustomed to their ways of thinking that they elicit negative thinking automatically. The first step to helping clients progress is to help them recognize the thoughts that automatically lead to negative emotional responses (Gautam et al., 2020). By examining the automatic thoughts, clients can learn to rethink and control their thinking. Clients learn how to investigate and gather data about their negative thoughts to determine their validity (Gautam et al., 2020). An important CBT technique for the treatment of depression is called reattribution (Hall, 2023). Many clients with depression tend to blame themselves for adverse events rather than seeking alternative explanations. Together with the therapist, clients review the evidence about the adverse events and try to examine the multiple factors that also come into play (Hall, 2023). Clients learn to reconceptualize their interpretations of events instead of internalizing them. For example, a client complains that all of her friends have suddenly turned against her. The therapist can ask the client for details about each of her friends. The client attributes her friends’ negative reactions to herself as being a result of her being not very smart or pretty. The therapist asks the client to describe the current events happening in each friend’s life. The client explains that one friend is going through a divorce, and another friend is moving out of state. The therapist helps the client to understand alternative
reasons that her friends may not want to socialize, such as going through an emotional divorce or feeling overwhelmed by a large move. Techniques such as role reversal or role- play may be useful in this case. Assigning homework is another component of CBT (Hawley et al., 2016; Young et al., 2014; Gautam et al., 2020). Some studies suggest that clients who completed homework assignments between sessions were more likely to make significant progress and continue progress after treatment compared with those who did not do homework assignments (Callan et al., 2012; Young et al., 2014). Some examples of homework assignments are reading relevant books or articles, practicing relaxation techniques, completing the weekly activity schedule (e.g., attending one social activity for the week), and writing thoughts and feelings in a journal (Callan et al., 2012; Young et al., 2014). Therapists and clients review their homework assignments to follow progress closely and reinforce new concepts. Research suggests that CBT provided in a group format is also an effective treatment for clients who have treatment- resistant major depression (Li et al., 2018). A group format may offer the additional benefits of allowing group members to give and receive support from one another. Group members can help others identify maladaptive thinking patterns that lead to maladaptive behaviors. In addition, group formats may help decrease participant dropout rates as well as improve depressive symptoms (Li et al., 2018).
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