Cognitive Behaviour Therapy with Older People

Trea Simpson

What is Cognitive Behaviour Therapy?

What does the therapy aim to do?What sort of interventions does it use?How long does it last?What does a CBT session look and sound like?- What are it’s characteristics?

Cognitive Behaviour Therapy

A short term, structured form of therapy which

provides patients with a rationale for understanding their problems

A vocabulary for expressing themselves and Training in techniques for surmounting

distressing affective states and solving problems

How does it work?

Different types of CBT- but all work focus on problematic patterns of thinking and behaviour.

Misinterpreting situations undermines how people cope and behavioural responses serve to maintain and exacerbate problems.

CBT aims to break this cycle by encouraging people to re-examine their thinking. Beliefs are a hypothesis to be tested. The therapist helps the client to explore alternative interpretations using cognitive and behavioural techniques.

Cognitive Model of Emotional DisordersPadesky and Greenberger, 1996

Thoughts

Behaviour Emotion

Biology

Environment

Characteristics Agenda Problem oriented Ahistorical Scientific Homeworks Collaborative Active and directive Socratic questioning Openness

How long does it take?

Usually consists of weekly sessions Typical course consists of eight to twelve

sessions- though this changes depending on the condition.

- 1 single 3 hour session for phobias- Years for BPD.

Cognitive theory

Based on an information processing perspective.

Beck states that information processing bias are present in all psychopathological states. (Beck 1967, 1976, 1987)

The faulty information processing is part of the complex symptom profile that serve to maintain the disorder.

Schema

A cognitive structure Content of schema is considered important

for emotional disorders 2 types of informational content in Beck’s

theory Beliefs: core constructs, absolute in nature taken

as truths e.g “I’m vulnerable” Assumptions: conditional, they are contingencies

between events and self appraisals e.g. “having a bad thought means I’m a bad person”

Learning experience

Danger schema formed (beliefs/ assumptions)

Critical incident

Schema activated

Negative Automatic Thoughts

Anxiety symptoms

Behavioural responses

Cognitive biases

Generic model of anxiety

disorder

Empirical support for the model 1

The classification system DSM IV has to identify those symptoms that are specific to the disorder. Cognitive symptoms of worrying and apprehension expectation are detailed as symptoms of GAD and PD respectively.

A cognition check list (CCL) can differentiate between people with problems of depression, and panic- generalised anxiety is less easy to discriminate from depression (Clark, Beck & Beck 1994).

Wells (1997) cites a number of studies where patients with anxiety report thoughts and visual fantasies concerning danger (death disease and social humiliation).

Think of an occasion when you were anxious- balloon experiment.

Beck’s Cognitive Theory of Depression

Negative Automatic Thoughts Systematic Logical thinking errors Depressogenic schemata

Beck’s Theory of DepressionEarly experiences

Core beliefs

Dysfunctional Rules

Critical incident (and activation of assumptions)

ProblemsDepressed mood Behaviour physiological Negative

problems Automatic Thoughts

Measurement of Negative Thinking

A number of scales have been developed to measure negative thinking. These show greater negative thinking in depressed people compared with controls; and greater than depressed people in remission. (Blackburn et al 1986; Eaves and Rush 1984)

Empirical support

Teasdale & Dent (1987) Induced temporary depressed mood with

previously depressed and never depressed groups.

Results- recovered depressed persons more likely to recall negative adjectives endorsed as self descriptive than never depressed group.

Stressor – Schema content match

People have specific vulnerabilities to depression. Schema content can predict the stressor likely to result in depression. 2 categories- Sociotropic (interpersonal) and autonomous/ self criticism.

Nietzel & Harris 1990 (cited in Leahy 2004) found a match between cognitive style and congruent life event in depressed patients. Also found that there were greater levels of depression in the sociotropy group.

Efficacy of CBT for Anxiety and Depression

Randomised Controlled Trials Clark et al used an RCT to compare cognitive therapy,

applied relaxation and imipramine in the treatment of Panic disorder (n= 64).

Comparisons with waiting list showed all three treatments were effective. Comparisons between treatments showed: cognitive therapy was superior to both applied relaxation and imipramine on most measures.

After 3 months CT superior to AT and imipramine. After 6 months CT= Imipramine but superior to RT. After 15 months CT superior to RT and imipramine

RCT Two psychological Treatments for Hyperchondriasis Clark et al 1998. N=48 randomly assigned to

CT or behavioural stress management (BSM).

Both superior to waiting list control group. CT < BSM on measures of hyperchondriasis

at mid treatment and post treatment.

RCT for PTSD

Ehlers et al 2003. N=97 (RTA survivors) CT < self help in reducing symptoms of

PTSD, depression , anxiety and disability. At follow up CT had fewer PTSD symptoms

than Self help.

6 year outcome of CBT of recurrent depression. Fava et al (2004) N=42 successfully treated with

antidepressants randomly assigned to CBT of residual symptoms or clinical management. In both groups antidepressants tapered then discontinued.

CT resulted in 40% relapse Clinical management 90% relapse

Efficacy of CBT

The effectiveness of cognitive therapy for the treatment of depression, anxiety, and an extensive list of other disorders, is now well supported by a large body of research.

Results of have been shown to translate to clinical practice. (Gillesphie et al 2002)

Efficacy of psychotherapy with Older Adults Meta–analytic review Robinson, Berman & Neimeyer 1990 Analysis of 58 studies Overall effect size for treatment vs no

treatment is 0.73 (0.8= large, 0.5= moderate, 0.2= small)

All forms of psychotherapy more effective than no treatment.

Outcome studies CBT

Tend to be completed for late life depression. See table- highlight that CBT is an effective

treatment for late life depression.

Obstacles

A Freudian view that older people lack the mental plasticity to change or benefit from psychotherapy.

Knight (1996) argues that those who work in the field tend to be more optimistic.

Myths and psychotherapy (Laidlaw et al 2003) You can’t teach an old dog new tricks. It must terrible getting old. Old people don’t want psychotherapy

Stages of CBT

1. Assessment and Formulation2. Socialisation3. Treatment- symptom specific (Cognitive

techniques- eliciting and modifying Negative Automatic Thoughts, Behavioural Techniques-activity, behavioural experiments)

4. Treatment schema based (Behavioural experiments, positive data logs)

5. Relapse Prevention (Blue prints)

Assessment and Formulation

The main purpose of assessment is to develop a formulation.

Formulation is a way to understand the idiosyncratic nature of the persons difficulties (Padesky and Greenberger 1995).

CBT formulation is suited to working with older adults because it is individualised.

Additional considerations for older adults

Cohort beliefs- shared beliefs and experiences of a generation. (Niederehe 1992 stigma of mental illness)

Role Investment- the importance and functions of roles carried or lost. (Champion and Power 1995 noticed gender differences).

Considerations for older adults

Socio cultural beliefs- the internalising or rejection of beliefs about aging in the society or culture in which older people live.

Intergenerational links- the stresses and supports of important close relationships. Thompson 1996 highlights relationship strains can trigger depression. E.g. differences in views on relationship.

Early experiences

Core beliefs Activating event

Cohort beliefs Intergenerational Linkages

Role investment Sociocultural contextDysfunctional Rules

ProblemsDepressed mood Behaviour physiological Negative

Health status

Treatment strategies cognitive

Identification and modification of negative automatic thoughts

Thinking biases. Common age related NAT’s

Its just my ageI’m a failure“If only” thinking

Treatment strategies cognitive cont..

Strategies for modifying NAT’s Examining the evidence The consequence of holding x belief Putting someone else in my shoes Reviewing past successful coping methods.

Treatment Strategies Behavioural

Activity scheduling – the importance of increasing activity levels.

Increase in pleasurable activities (this needs to be realistic and possible).

Practical problem solving. Relaxation training.

Anxiety

King and Barrowclough (1991) showed 7/10 benefited from standard interventions of anxiety.

Evidence in this area is impoverished.

Depression in Dementia.

Teri et al reported two behavioural treatments (one focussing on problem solving and 1 focussing on increasing pleasant events.) Both were shown to have beneficial effects for the person with dementia and their care giver.

Memory Problems

Information presented slowly Mnemonic devices, (say it show it do it) Folders/ files/ note books Flip chart in sessions Rehearse homework's in session Tape sessions

Multi morbidity

Communication with multi disciplinary team e.g. medications, inadequate resources.

Internalised ageism

Dispel some myths with recent research. Books such as Aging: exploding the myths

WHO 1999

Story Telling

Inclination to provide extensive details. Set up ground rules once alliance is

established- permission to interrupt. Provide frequent summaries.

References Beck, A.T. (1963) Thinking and depression: 1, Idiosyncratic content and cognitive

distortions. Archives of General Psychiatry. 9, 324-333 Beck, A.T. (1976) Cognitive therapy and the emotional disorders. New York.

International Universities Press. Beck,A.T. ; Rush,A.J. ; Shaw,B.F. & Emery,G. (1979) Cognitive therapy of

depression. New York. Guilford Press. Blackburn, I.M. & Twaddle, V. (1999) Cognitive therapy in action: A practitioner’s

casebook. London. Souvenir Press (Educational & Academic) Ltd. Blackburn, I. M., Jones, S. Lewin, R. J. P. (1986) Cognitive style in depression.

British Journal of Clinical Psychology Butler, G. & Mathews, A (1983). Cognitive process in anxiety. Advances in behaviour

therapy, 5, 51-62. Butler, G. & Mathews, A. (1987) Anticipatory anxiety and risk perception. Cognitive

Therapy and research, 91, 551-565. Clark, D.A., Beck, A. T. & Beck, J. (1994) Symptom differences in major depression,

dysthymia, panic disorder, and generalised anxiety disorder. American Journal of Psychiatry, 151, 205-209.

Clark, D.A. & Steer, R.A (1996) Empirical status of the cognitive model of anxiety and depression. In Salkovskis, P. M. Ed Frontiers of cognitive Therapy. New York. The Guilford Press.

References

Eccles, M., Mason, J. (2001) How to develop cost-conscious guidelines. Health technology assessment.

Ingram, R.E. (1990) Depressive Cognition: models mechanisms and methods. In Ingram, R.E. Ed. Contemporary psychological approaches to depression: theory research and treatment. New York: Plenum Press.

Mathews, A., Richards, A. & Eyesenk, M.W. (1989). The interpretation of homophones related to threat in anxiety states. Journal of Abnormal psychology, 98, 31-34.

Roth, A. & Fonagy, P. (1996) What works for whom? A critical review of psychotherapy research. New York. Guilford Press.

Salkovskis,P.M. (Ed.) (1996) Frontiers of cognitive therapy. New York. Guilford Press.

Teasdale, J. D. (1988) Cognitive Vulnerability to persistent depression. Cognition and Emotion, 2- 247-74.

References- effectiveness

Hollon, S. D., & Beck, A. T. (2004). Cognitive and cognitive behavioral therapies. In M. J. Lambert (Ed.), Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (pp. 447-492). New York: Wiley.

Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49(1), 59-72.

Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting & Clinical Psychology, 71(6), 1058-1067.

Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. G. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759-769.

Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psychological treatments for hypochondriasis: A randomised controlled trial. British Journal of Psychiatry, 173, 218-225.

Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., et al. (2003). A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttraumatic stress disorder.[see comment]. Archives of General Psychiatry, 60(10), 1024-1032.

Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., & Grandi, S. (2004). Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. American Journal of Psychiatry, 161(10), 1872-1876.

Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., et al. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Archives of General Psychiatry, 60(2), 145-152.

References- evidence for the model

Leahy, R. (2004) Contemporary cognitive Therapy: Theory Research and Practice. London Guilford Press.

Teasdale, J. D., & Dent, J. (1987). Cognitive vulnerability to depression: An investigation of two hypotheses. British Journal of Clinical Psychology. 26, 113-126.