CBT IN THE CITY

October 2012

Message From the Clinical Director page 2

What is Behavioral Activation? Find out more on how to overcome your problems using BA page 3

What is Depression? Diagnosis from the doctor page 8

Message From the Clinical Director

The recession is underway for another wave and so it is important to keep hold of the positives and press on. There is the tendency to listen to the negatives and worry but worrying can't change the outcome but you can have control over how you respond to the negative automatic thoughts. Don't treat every thought as fact but allow them to pass through and focus on what is important to you like friends, family, hobbies, work etc. Looking at the bigger picture can help to treat negative automatic thoughts with scepticism as the bigger picture may have a bigger drawing power. Mood change is also a big motivator and so when engaging in the bigger picture stuff then rate your mood before and after. If mood improves after an activity that is relevant to you then try and try again, until your mood has a consistency to it.

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CBT London and the Home Counties

Our head office is based in Harley Street, London, while we also hold London CBT Clinics at the

Healix Wellbeing Centre in Southgate, North Church

Road Clinic in Highbury and Islington Brixton,

Camberwell and Walthamstowe. In the home counties we have

CBT Therapists available on the network in Berkshire, Buckinghamshire, Essex, Norwich, St Albans in Hertfordshire, Kent , Surrey and Sussex. For more information, book an appointment or enrol in a Group CBT Programs you will need to contact us, register online or telephone 0207 467 1508

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3 CBT in the City Ltd Registered company in UK:6709268. CBT in the City is a registered Trademark copyright 2010 and all work produced and published is the property of CBT in the City Ltd. Any reproduction is prohibited 2012

2012

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Behavioral Activation Therapy What is Behavioral Activation? In short Behavioral Activation is a treatment for depression that holds that context rather than internal factors such as cognitions is a more efficient explanation for depression, and a more efficacious realm in which to intervene. In other words, BA seeks to help people understand environmental sources of their depression, and seeks to target behaviors that might maintain or worsen the depression. C. B. Ferster (1973) proposed a behavioral analytic theory of depression providing an alternative to psychoanalytic theory that was prominent at that time. Peter Lewinsohn and colleagues at the University of Oregon were the first to develop Behavioral Activation as a treatment for depression, and developed the treatment to increase pleasant activities for depressed individuals (Lewinsohn, 1994; Lewinsohn, Biglan, & Zeiss, 1976; Lewinsohn & Graf, 1973). While committed behavior therapists continued to utilize this approach much more research was conducted on cognitive-behavioral treatment for depression, which incorporated activation but focused mainly on the typical distortions in thoughts and beliefs that are characteristic of depressed individuals. Throughout the 1980s and 1990s CBT became the most widely studied treatment and consistently demonstrated effectiveness in treating depression, anxiety and other disorders. In 1996 Jacobson and colleagues (Jacobson, et al, 1996) conducted a study of the effective ingredients in CBT for depression. They found that there were no differences in treatment outcome between CBT compared to behavioral activation (BA) alone. Another major study comparing BA, CT, and Antidepressant Medication was conducted by Jacobson and colleagues, and continued after the untimely death of Neil Jacobson in 1999. A description of BA as developed in that study was published in a refereed journal (Jacobson, Martell, & Dimidjian, 2001) and in the book Depression in Context: Strategies for Guided Action  (Martell, Addis, & Jacobson, 2001). Results of that study showed BA to be as efficacious as antidepressant medications and to have slight advantage over CT in the treatment of moderate to severe depression (Dimidjian, et al., in press) The BA model proposes that life events, which can include specific or loss, biological predispositions to depression, or the daily hassles of life, lead to individuals experiencing low levels of positive reinforcement in their lives. Furthermore, many behaviors used to cope with negative feelings that make the individual feel better in the short-run but are detrimental in the long-run increase through a process of negative reinforcement. It is natural for a person that feels sad and is no longer finding pleasure in activities that were previously enjoyed to attempt to cope by withdrawing socially, ceasing to engage in activities and "shutting down". The problem is that such coping strategies do not help alleviate depression, they make it worse. BA targets inertia. When depression zaps motivation, the BA approach is to work from the "outside-in", scheduling activities and using graded task assignments to allow the client to slowly begin to increase their chance of having activity positively reinforced. BA targets avoidance. Behavioral analytic theory recognizes that the outcome or function of a behavior is more important than the form of the behavior. Formally, for example, sitting on the front stoop of one's house resting your head in your hands is always just that - sitting. However, you may be sitting there waiting for a friend to pick you up to go to a show or you may be sitting there to escape from a nasty argument with a partner. In those two instances "just sitting" serves very different functions. In the first it functions as an approach behavior, engaging in life. In the second it is an escape or avoidance behavior. Avoidance behavior has not been a primary target of most treatments for depression, in BA it is the primary target. BA is short-term. In the primary outcome study (Dimidjian, et al., in press) participants had up to 24-sessions of treatment. BA is intended to be a focused, brief treatment for the alleviation of depression. 4 CBT in the City Ltd Registered company in UK:6709268. CBT in the City is a registered Trademark copyright 2010 and all work produced and published is the property of CBT in the City Ltd. Any reproduction is prohibited 2012

Questions and Answers about Depression and Behavioral Activation Is depression an illness that will get worse if not treated? It is a popular view to consider depression an illness, often compared to diabetes. However, this view is not accepted by everyone in the behavioral health field. Those professionals that seek a biological explanation consider depression an illness, and there are several popular press books that promote this idea, as do television commercials for antidepressant medications. There is little data to support a purely biological perspective on depression. This does not mean that depression is the same as sadness, or that it is not serious. Many people that experience depression suffer tremendously and need not suffer without help.Depression is best seen as a syndrome, or a compilation of behavioral patterns. Certainly some people are predisposed to depression by family history and so on. Having depressed parents or grandparents not only transfers genetic material, but also models of coping with life that become a part of a person's repertoire. A bio-psycho-social perspective on depression considers biology, individual behavior patterns and environmental variables rather than any of these in isolation as potential causal factors. In other words the entire context of a person's life is taken into account rather than focusing on one specific area such as biology or environment. Statistically, depression in many people lasts for six months or less and remits on its own, even without treatment. For others depression can last for years and become chronic.It is true that a person that has had one major depressive episode is more likely to have a second, and after a second the odds of a third increase. Roughly 60% of people that have been depressed once will be depressed again. Some consider this as partial evidence that there is a medical illness occurring. However, the same pattern has been found for divorce. Second marriages are less likely to succeed than first marriages, and the odds get worse for third or fourth marriages. One would never conclude that divorce is a disease that will repeat itself if untreated through medicine! Rather, it may also be the case that certain patterns of behavior and thinking occur that become habitual, and because people do not consist of separate minds and bodies, but of a physical body including a brain and central nervous system, changes may also occur in the brain that interact with these behavioral patterns. Once a person has experienced a certain way of coping with life, even if it feels bad, it may become engrained as a method for coping.Treatments for depression can help, and provide structure and support to allow an individual to recover more quickly. What causes depression? There are several differing views on the cause of depression. As mentioned above, the bio-psycho-social view considers heritability, individual behavior patterns and environmental variables as causes for a person becoming depressed. From a behavioral perspective, the feelings one experiences following losses, disappointments, daily difficulties with money, family, or jobs, and so on are natural feelings. People vary in their levels of tolerance for negative feelings, and their sensitivity to them. When life is unrewarding or when one has to work extremely hard for very little reward, the result can be feeling sad, losing interest in activities, and decreased energy. When one feels low energy, fatigued or has no interest in activities it is understandable that a person may cope by sleeping longer hours, staying at home more often than usual, or isolating from friends and loved ones. The life events or the behaviors that follow may have an impact on biochemical changes in the body, the decrease in activity will prompt less activity, and a person may begin to feel hopeless and focus on all that is wrong in his or her life. This has been referred to as the vicious cycle or downward cycle of depression. What is wrong with considering depression a medical illness? Modern psychiatry has discovered many helpful medications that alleviate suffering for many people who experience variety of problems. At the same time, psychological and behavioral research has also validated psychotherapeutic and behavioral therapy methodologies that relieve

suffering. The idea that depression is a "medical illness" suggests that it requires a medical cure. This is more than a question of semantics. From a psychological perspective there is much that a person can do, often with the help of a professional, to cope with and treat depression besides taking medication. Psychotropic medication does not work for everyone, and some people do not tolerate the side effects of medication. Depression can be considered a behavioral disorder that often requires treatment by a mental health professional. However, there are treatment options, including antidepressant medication, cognitive-behavior therapy (CBT), interpersonal psychotherapy (IPT), and behavioral activation therapy (BA), that have all been studied and supported by randomized clinical trials. The problem with thinking of depression as an illness is that it implies that the depressed person is helplessly in the grasp of something completely uncontrollable. This is not the case, and one should have hope that changes in activity, life situations, long-held beliefs about self and world can all help to alleviate the suffering involved in depression. For further reading see:Antonuccio, D. W., Danton, W. G., & DeNelsky, G. Y. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 26(6), 574-585.Valenstein, E. S. (1998). Blaming the brain: The truth about drugs and mental health. New York: Free Press. How do I know if I'm depressed? Behavioral health problems are not as clear-cut as biological diseases like a clogged artery or a broken bone. Diagnostic criteria change through the decades and are based on research and consensus of psychiatrists, psychologists and other mental health researchers and practitioners. The diagnoses are listed in a publication called the Diagnostic and Statistical Manual of Mental Disorders, which is now in its fourth edition:American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, (1994, 2000). Washington, D.C.: Author.Commonly called the DSM-IV, the manual provides the following criteria for diagnosing depression, considering that five or more of the symptoms have been present during a consecutive 2-week period: (DSM-IV-TR, pp. 356)Depressed mood most of the day, nearly every day.Markedly diminished interest or pleasure in all or almost all activitities most of the day, nearly every day.Significant weight loss when not dieting or a decrease or increase in appetite nearly every day.Difficulty sleeping, or sleeping too much nearly every day.Noticeably physically agitated or slowed down, as observed by others nearly every day.Fatigue or loss of energy nearly every day.Feelings of worthlessness or excessive guilt nearly every day.Diminished ability to concentrate or make decisions nearly every day.Recurrent thoughts of death or suicide.If you believe that you are experiencing these symptoms or if others have told you that they observe these patterns, you might consider seeking an evaluation from a licensed behavioral healthcare provider. Your primary care physician can also diagnose depression. Keep in mind, however, that you have options regarding treatment. For some people medication is a simple solution, for others cognitive-behavioral therapy, behavioral activation therapy or interpersonal psychotherapy is a better option, and for others a combination of therapy and medication can help. 6 CBT in the City Ltd Registered company in UK:6709268. CBT in the City is a registered Trademark copyright 2010 and all work produced and published is the property of CBT in the City Ltd. Any reproduction is prohibited 2012

CBTMONTHLY 10 Harley Street

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A & D

What is depression? Depressed mood most of the day, nearly every day.Markedly diminished interest or pleasure in all or almost all activitities most of the day, nearly every day.Significant weight loss when not dieting or a decrease or increase in appetite nearly every day.Difficulty sleeping, or sleeping too much nearly every day.Noticeably physically agitated or slowed down, as observed by others nearly every day.Fatigue or loss of energy nearly every day.Feelings of worthlessness or excessive guilt nearly every day.Diminished ability to concentrate or make decisions nearly every day.Recurrent thoughts of death or suicide.

DC Diagnosis Corner

8 CBT in the City Ltd Registered company in UK:6709268. CBT in the City is a registered Trademark copyright 2010 and all work produced and published is the property of CBT in the City Ltd. Any reproduction is prohibited 2012