Managing treatment Starting treatment

The first treatment interview has four main objectives:

• to establish a warm, collaborative therapeutic alliance

• to list specific problems and associated goals, and to select a first problem to tackle

• to educate the patient in the cognitive model, explaining and illustrating the vicious circle that maintains depression

• to provide the patient with first-hand experience of the focused, workman-like, empirical style of cognitive therapy.

These convey two important messages: (1) it is possible to make sense of depression; (2) there is something the patient can do to combat it. These messages immediately address the hopelessness and helplessness characteristic of mood disorder.

Identifying problems and goals

The problem list usually includes symptoms of depression. It may also contain aspects of other disorders (e.g. panic attacks), problems in living (e.g. family conflicts), and, in some cases, long-standing psychological problems (e.g. fear of intimacy). Developing the list has a number of advantages. It provides the therapist with a 'map of the territory' which suggests possible targets for intervention, as well as an opportunity to foster the therapeutic relationship by demonstrating empathy for the patient. It suggests that apparently chaotic experience can be broken down into manageable problem areas. Goal identification then implies that progress is possible.

Introducing the cognitive model of depression

The therapist's next task is to demonstrate how emotion and behaviour are influenced by negative thinking, and to relate this to the patient's personal experience using material derived from the session. The therapist explains that the patient will learn to notice negative automatic thoughts, to stand back, question them, and develop more realistic and helpful perspectives. Patients are often doubtful about their ability to do this. It is important therefore to present cognitive therapy as a learning opportunity during which skills can be acquired, step by step, with the therapist's guidance. The therapist is not obliged to convince patients that the approach will work for them. What is helpful is a recognition that these ideas make sense, and a willingness to try them in practice. The extent to which this is achieved may have a lasting impact on treatment response.(28>

Where to start?

A target for immediate intervention is chosen towards the end of the first session, and an appropriate homework task agreed upon. Possible homework tasks include: listening to an audiotape of the session and noting important points (this assignment follows every session), a reading assignment, (48) and a self-monitoring assignment. The initial target varies. Where the patient is only relatively mildly depressed, and remains active and capable of experiencing interest and pleasure, monitoring negative automatic thoughts can begin right away. Where the depression is relatively severe, and there are significant behavioural and motivational deficits, it is best to begin with behavioural interventions.

Behavioural interventions

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