TREATING DEPRESSION WITH CBT i TREATING DEPRESSION WITH COGNITIVE ...

189 Pages·2017·2.27 MB·English

by  Sara Antunes Alves

Running head: TREATING DEPRESSION WITH CBT i

TREATING DEPRESSION WITH COGNITIVE BEHAVIOURAL THERAPY:
EXPLORING THERAPIST TECHNIQUE

Sara Antunes-Alves, M.A.
Department of Educational and Counselling Psychology
McGill University, Montreal
February 2017

A thesis submitted to McGill University in partial fulfillment of the requirements of the degree
of Doctor of Philosophy in Counselling Psychology

© Sara Antunes-Alves 2017
TREATING DEPRESSION WITH CBT ii

TABLE OF CONTENTS
List of Tables……………………………………………………………………………………..iv
List of Appendices…………………………………………………………………………….….v
Abstract………………………………………………………………………………………...…vi
Résumé…………………………………………………………………………………….…....viii
Acknowledgements………………………………………………………………………………..x
Contribution of Authors………………………………………………………………………….xii
Introduction………………………………………………………………………………….….xiii
CHAPTER 1…………………………………………………………………………………..…23
Review of the Literature………………………………………………………………….….23
The Cognitive Theory of Depression………………………………………………………..23
Cognitive Processes in Depression: The Role of Cognitive Errors………………….………24
Cognitive Processes in Depression: The Role of Coping Strategies…………………..…….26
Exploring the Role of Therapist Technique in Therapeutic Change.…………………….….29
CBT Techniques, Cognitive Errors, and Coping Strategies: A Need to Bridge the Gap…....36
Introducing Study 1……………………………………………………………..………………..40
CHAPTER 2……………………………………………………………………………….…….41
Abstract……………………………………………………………………………………...…42
Method…………………………………………………………………….…………………...48
Results…………………………………………………………………………………….……55
Discussion………………………………………………………………………………….…..61
References…………………………………………………………………………………...…70
Bridging Studies 1 and 2…………………………………………………………………..……..96
TREATING DEPRESSION WITH CBT iii

CHAPTER 3……………………………………………………………………………………..98
Abstract………………………………………………………………………………….……..99
Method……………………………………………………………………………………..…...105
Results………………………………………………………………………………………...111
Discussion…………………………………………………………………………………….116
References………………………………………………………………………………….…124
CHAPTER 4………………………………………………………………………………..…..137
Summary of Findings and Clinical Considerations…………………………………….…….137
Study 1…………………………………………………………………………………...…138
Study 2……………………………………………………………………………...………144
Final Conclusions and Contributions……………………………………………………….…..148
References………………………………………………………………………………………153
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List of Tables
Table 1-1: Means and Standard Deviations of Therapist Interventions (CPIRS)
Table 1-2: Intercorrelations Among Facilitating Interventions
Table 1-3: Intercorrelations Among Authoritative Support Interventions
Table 1-4: Intercorrelations Among Structuring Interventions
Table 1-5: Intercorrelations Among Behavioural Interventions
Table 1-6: Intercorrelations Among Cognitive Interventions
Table 1-7: Hierarchical Multiple Regressions Predicting Depression with Facilitating,
Authoritative Support, Structuring, Behavioural, and Cognitive Interventions
Table 1-8: Hierarchical Multiple Regressions Predicting Late Cognitive Errors with
Facilitating, Authoritative Support, Structuring, Behavioural, and Cognitive
Interventions
Table 1-9: Hierarchical Multiple Regressions Predicting Late OCF with Facilitating,
Authoritative Support, Structuring, Behavioural, and Cognitive Interventions
Table 2-1: Hierarchical Multiple Regressions Predicting Depression, Late Cognitive Errors, and
Late OCF, with Therapist Intervention Focus
Table 2-2: Hierarchical Multiple Regressions Predicting Depression, Late Cognitive Errors, and
Late OCF with Therapist-Patient Match
TREATING DEPRESSION WITH CBT v

List of Appendices
APPENDIX A…………………………………………………………………………………..179
APPENDIX B………………………………………………………………………………..…182
APPENDIX C…………………………………………………………………………………..184
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ABSTRACT
A seriously debilitating condition, major depressive disorder (MDD) is the most common
psychiatric illness (Kleine-Budde et al., 2013) said to become the foremost contributor to disease
burden in high income countries like Canada by 2030 (Mathers & Loncar, 2006). Cognitive
behavioural therapy (CBT) is a widely used treatment with ample support for its efficacy in
treating depression. It is based on the notion that depression is maintained chiefly by
dysfunctional beliefs that influence motivation, behaviour, and affect (Beck, Rush, Shaw, &
Emery, 1979). As such, it is known for its abundance of goal-oriented, systematic interventions
aimed at modifying everyday thoughts, behaviours, and emotions to alleviate symptoms of
depression (Keshi, Basavarajappa, & Nik, 2013). Decades of outcome studies demonstrate
CBT’s effectiveness in treating depression (Butler, Chapman, Forman, & Beck, 2006). However,
researchers remain confused about the specific elements responsible for its success (Webb,
Auerbach, & DeRubeis, 2012). While there have been numerous efforts toward better
understanding the mechanisms of change in CBT, much of this body of research has been
criticised for its methodological or conceptual limitations (Drapeau, 2014).
This dissertation presents two distinct studies that serve to address some of these
limitations to better our understanding of the specific therapist behaviours that contribute to
patient improvement. The first examines specific interventions that occur in CBT with depressed
patients and assesses their individual relationships with symptoms of depression, and late therapy
cognitive errors and overall coping functioning. Addressing the persistent common vs. specific
factor debate in the psychotherapy community, it identifies both interventions specific to CBT,
as well as some common to all therapies related to the alliance. The second study is an extension
of the first, exploring the focus of therapist interventions on two pivotal concepts in CBT:
TREATING DEPRESSION WITH CBT vii

cognitive errors and coping strategies. Inspired by methods used in psychodynamic research, it
presents a method to gauge therapist accuracy in CBT based on therapist-patient interaction on
these concepts. The relationships between therapist accuracy conceptualized in this way and the
same three dependent variables are investigated. Practical clinical and research implications of
both studies are discussed throughout the dissertation.
TREATING DEPRESSION WITH CBT viii

RÉSUMÉ
Le trouble dépressif majeur (TDM), une pathologie débilitante sévère, constitue le
trouble psychiatrique le plus répandu (Kleine-Budde et al., 2013) et est en voie de devenir, d’ici
2030, l’élément qui alourdira le plus le fardeau des maladies qui touchent les pays à revenu élevé
comme le Canada (Mathers & Loncar, 2006). La thérapie cognitivo-comportementale (TCC)
repose sur la notion selon laquelle la dépression est causée principalement par des croyances
dysfonctionnelles qui influent sur la motivation, le comportement, et les affects (Beck, Rush,
Shaw, & Emery, 1979). À cet égard, cette thérapie est reconnue pour son abondance
d’interventions systématiques orientées vers un but, soit modifier les pensées, émotions, et
comportements quotidiens pour soulager les symptômes de la dépression (Keshi, Basavarajappa,
& Nik, 2013). Les études axées sur les résultats menées au cours des dernières décennies ont
démontré que la TCC était efficace dans le traitement de la dépression (Butler, Chapman,
Forman, & Beck, 2006). Toutefois, les chercheurs s’interrogent sur les éléments précis qui ont
contribué à ce succès (Webb, Auerbach, & DeRubeis, 2012). Malgré tous les efforts visant à
mieux comprendre les mécanismes de changements apportés par la TCC, ce domaine de
recherches a, dans une grande mesure, fait l’objet de critiques en raison de ses limites
méthodologiques ou conceptuels (Drapeau, 2014).
La présente thèse présente deux études distinctes qui traitent de certaines de ces limites
dans le but d’accroître notre compréhension des approches spécifiques des thérapeutes pour
améliorer la condition des patients. La première décrit des interventions précises réalisées dans le
cadre de la TCC avec des patients souffrant de dépression afin de déterminer leurs effects sur les
symptômes de la dépression, les erreurs cognitives, et le fonctionnement global du coping. Dans
le cadre du débat qui persiste au sein de la communauté des psychothérapeutes, divisés sur la
TREATING DEPRESSION WITH CBT ix

question des facteurs communs et des facteurs spécifiques, cette étude décrit les deux types
d’intervention propres à la TCC, ainsi que certaines interventions communes à toutes les
thérapies liées à l’alliance thérapeutique. La deuxième étude constitue une prolongation de la
première en ce qu’elle explore les interventions thérapeutiques à l’aide de deux concepts clés en
TCC: les erreurs cognitives et les stratégies de coping. S’inspirant des méthodes utilisées en
recherche psychodynamique, cette étude offre une méthode qui permet d’évaluer le degré de
précision des thérapeutes qui pratiquent la TCC en fonction de l’interaction thérapeute-patient
basée sur ces concepts. Elle se penche aussi sur le rapport entre le degré de précision des
thérapeutes ainsi conceptualisé et les trois mêmes variables dépendantes. Les implications des
deux études sur le plan de la recherche et de la pratique sont également analysées tout au long de
la thèse.
TREATING DEPRESSION WITH CBT x

ACKNOWLEDGMENTS
This PhD was made possible by more than just my own obsessive work habits, vanity,
and personal sacrifice – I was supported by many along the way. This is a formal declaration of
thanks and acknowledgement of my army of devoted helpers.
I would like to thank one of the funniest and most humble medical doctors I got to know,
Dr. Gail Myhr, for furthering my training in CBT and for her contribution to my comprehensive
exams. Sincere thanks to the members of my dissertation committee, Dr. Ueli Kramer and Dr.
Marina Milyavskaya, for their approachable nature, insightful comments, and thorough feedback.
I am indebted to my thesis supervisor, Dr. Martin Drapeau, for his trust in me, flexibility, and
reassurance along the way. I am glad we got to know each other more personally and you still
appreciated my dry wit. To my professor and clinical supervisor Dr. Jack De Stefano, I don’t
think I would have gotten into this program without you. Our chats about anything and
everything over the years have always made the oftentimes cold and secluded MPPRG lab a
cosier place for me. To all my clinical supervisors, instructors, and clients over the years: I
cherish all that you have taught me and credit my passion for my work to you. You are always
making me better.
To all my PhD friends, my compatriots – those down in the trenches with me – I hope we
can all look back at this era of our life with pride and nostalgia and give ourselves a whole-
hearted pat on the back. This wasn’t easy. A special thank you to Tyler Brown: I have found in
you a confidante through our hours of philosophical discussion and endless laughter; to Thea
Comeau: you have helped me more than you know, we are kindred spirits; to Deborah
Schwartzman: your kindness and courage from day one have never faltered; there isn’t a bad