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Cognitive Behavioral Therapy Strategies

• A practical guide for clinicians using Cognitive Behavioral Therapy for Depression (CBT-D) with Veterans
• It can supplement the manual "Cognitive Behavioral Therapy for Depression in Veterans and Military Servicemembers: Therapy Manual" (Wenzel, Brown, & Karlin, 2011).
• The resource aligns with typical therapy phases:
  • First section (pages 6-31) covers the Initial Phase of CBT
  • Second section (pages 32-99) addresses the Middle Phase of CBT
  • Last section (94-107) pertains to the Later Phase of CBT

Initial Phase

• Includes a preliminary assessment and case conceptualization, to help clinicians target problem areas and to identify evidence-based interventions
• Aims to reduce depression symptoms
• Helps Veterans understand CBT's structure and process
• Works to generate treatment goals

Middle Phase

• Focuses on the provider and Veteran working together to address treatment goals by the provider selecting the most appropriate behavioral and cognitive techniques

Later Phase

• Concentrates on the Veteran's progress toward treatment goals
• Evaluates how well techniques are applied to alleviate depressive symptoms.
• Focuses on creating a relapse prevention plan

Suggestions for using the guide:

• Select relevant handouts for each Veteran and provide them copies
• Maintain folders with handouts for easy access
• Use handouts to reinforce session ideas serves transitional objects for discharge and relapse prevention planning

What to Expect in CBT

• CBT is evidence-based and effective in treating depression
• Follows a structured approach with clear goals for symptom improvement, including homework assignments
• Psychoeducational, skill-based approach helps patients learn tools for coping with current problems
• Involves identifying and achieving specific treatment goals while tracking progress
• Typically lasts 16-20 weeks
• Requires attendance at weekly, approximately 50-minute sessions
• Requires active participation with a focus on the present
• Collaborative, as expertise is shared to tailor treatment to needs

What is Cognitive Behavioral Therapy?

• Cognitive Therapy + Behavioral Therapy = Cognitive Behavioral Therapy
• Cognitive knowing/recognizing experiences
• Cognitive model focuses on thinking and thoughts related to mood, physiological responses, and behaviors
• teaches how to change thoughts, beliefs, and attitudes that contribute to depression

Behavioral Model

• Depressed individuals often lack enough positive reinforcement to maintain happy, adaptive behavior
• Two behavioral patterns associated with depression:
  • Low positive feelings from life activities
  • High rate of negative consequences

Phases of CBT

• Initial: Assessment, motivational enhancement, socialization into CBT
• Middle: CBT conceptualization, treatment goals/plan, behavioral/cognitive strategies
• Late: Relapse prevention, termination, boosters, follow-up

Steps of CBT

• Step 1: Become aware of: Automatic thoughts, feelings, core beliefs, behaviors, physical reactions, environment
• Step 2: Examination: Thoughts are not facts, examine evidence, look for proof, question/challenge irrational beliefs
• Step 3: Create alternative thoughts: Increase positive self-talk, reduce negative automatic thoughts, replace irrational beliefs

Session Format

• Complete PHQ-9 in waiting room
• Check in: Review scores, review chart, mood check, medication, drug/alcohol use
• Bridge from last session by discussing its important and learnings
• Agenda setting for topics and homework
• Discussion of Agenda items and identifying key thoughts/behaviors
• Implement a CBT strategy and encourage application/generalization of strategies
• Provide periodic summaries and feedback
• Homework assignment for next week and likelihood
• A final summary and session feedback

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

• The PHQ-9 measures the frequency of depression symptoms over the past week
• Responses range from "Not at all" (0) to "Nearly every day" (3)
• Total scores indicate depression severity:
• 1-9: No Depression
• 10-14: Mild Depressive Symptoms
• 15-19: Moderate Depressive Symptoms
• 20-27: Severe Depressive Symptoms

Assessment/Case Conceptualization/Treatment Planning

• Gathering specific information can improve contributing factors, understanding symptoms and their development to allow for the creation of treatment plans
• The process involves considering:
  • Symptoms
  • Formative influences
  • Biological, genetic, and medical factors
  • Situational/interpersonal issues
  • Strengths and barriers
  • Typical automatic thoughts, emotions, and behaviors
  • Core beliefs
  • Hypothesis
  • Goals
  • Treatment plan and selecting strategies

SMART Goals

• Setting goals helps develop a pathway, and they should be:
  • Specific: Identify what to take place (Who, What, When, Where, How?)
  • Measurable: Quantifiable to track progress
  • Achievable: Attainable and based on available resources
  • Realistic: Personally meaningful and relevant
  • Timely: With a clear time-period

Activity Monitoring

• Establishes behavioral patterns
• Identifies when activities support or go against emotions
• Encourages participation in pleasant activities
• Recognizes activities that give a sense of accomplishment/fulfillment
• Identifies things to change or include in a regular routine
• Determines new goals
• Highlights activities that keep one stuck in a rut
• Identifies ways to better organize time

Relaxation: Benefits & Tips

• The goal is to reduce the health effects of stress
• Relaxation involves strategies to reduce tension rather than simply resting
• Relaxation benefits include:
  • Improved mood
  • Increased energy and productivity
  • Improved concentration and focus
  • Improved sense of control over stress and daily demands
  • Increased self-confidence
  • Greater ability to handle problems
  • Decreased anxiety and other negative emotions such as anger and frustration
  • Increased blood flow to muscles
  • Lower blood pressure, breathing rate, and heart rate
  • Decreased pain

Deep Breathing

• Become aware of breathing, putting one hand on the abdomen and the other on the chest
• Slowly inhale, imagine air flowing deeper into belly, pausing to take a breath
• As exhaling, let any tensions melt away
• Notice how cool air feels when it enters the nose
• Let breath become smooth and slow, feeling the belly/ribcage expand outward with each breath

Progressive Muscle Relaxation

• Build tension in lower arms by making fists, and hands using the tension (PAUSE 5 seconds)
• Release hands/lower arm tension, then relax in chair or bed (PAUSE 10 seconds)
• Build upper arm tension by pulling arms back and in, feeling/focusing on tension (PAUSE 5 seconds)
• Release arm tension for arms to relax at sides. (PAUSE 10 seconds)
• Flex feet/pulling toes toward upper body, building lower leg tension, hold this tension (PAUSE 5 seconds)
• Release lower leg tension, (PAUSE 10 seconds)
• Build upper leg and buttocks tension, and hold this tension (PAUSE 5 seconds)
• Release upper leg and buttocks tension, (PAUSE 10 seconds)
• Pulling the abdomen toward to spine to increase its tension (PAUSE 5 seconds)
• Relaxed from abdomen tension with controlled breathing with comfort (PAUSE 10 seconds)
• Using a deep breath in, build tension chest for a few second
• Slowly, let the air flow in/out of your body normally
• Build neck tensions with shoulder blades into your ears
• Release after a moment to relax
• Mouth, jaw and throat can build tensions by clenching teeth and turning mouths back into a smile
• Eyes and your forehead tensions can occur by holding eye brows town and closed
• Scalp tension can be developed by wrinkles and pulling your forehead as high as possible

Guided Imagery

• Imagine walking down a path toward the special place for comfort
• Path can be either outside and inside
• As walking down the path, imagine the worries and stresses leaving you to enjoy journey
• Noticing down along at the path what the temperature and grounds are, feel tension leave
• Walk path until own special spot arrive, to enter place (PAUSE 10 sec)
• Arriving at the relaxing and peaceful place.
• Hear the surrounding sounds and fragrance before you.
• Reach out, and touch one thing to have the texture
• Look above to find different colors and sights from its location
• Noticing from their texture and how it can effect skin
• Be aware of different objects from their shade of colors, shapes, effects and lights

Thought-Stopping Techniques

• Unwanted, intrusive, or obsessive thoughts that can cause strong emotional/physical reactions, as a strategy to reduce/stop rampant thoughts by
  • Recognizing the negative thought process (e.g., excessive worrying, exaggerated fears, rumination)
  • Closing eyes and shouting "STOP"
  • Visualizing a stop sign
  • Thinking of a pleasant memory
  • Singing your favorite song
  • Stopping and taking ten deep breaths
  • Scheduling worry time

Automatic Thoughts/Intermediate Beliefs/Core Beliefs

• Automatic thoughts: words, image, a memory, a physical sensation, an imagined sound, or based on intuition; a surface-level, meaning they just happen by popping in head
• Intermediate beliefs: thoughts responsible for maintaining anxiety/depression
• Core beliefs: are considered to be at the root, or deepest level, of our thinking

Problem Solving (ITCH) framework

• Identify problem
• Think about Potential Solutions
• Choose The Best Solution within an Action Plan to be completed
• How well did it work