CBT for Depression: An Integrated Approach

Background: Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients do not complete therapy, do not respond to it, or subsequently relapse. Non-responders, and those at risk of relapse, are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk. This is a heterogeneous group of clients who are currently difficult to treat. Aim: The aim was to develop a CBT model of depression that will be effective for difficult-to-treat clients who have not responded to standard CBT. Method: The method was to unify theory, evidence and clinical strategies within the field of CBT to develop an integrated CBT model. Single case methods were used to develop the treatment components. Results: A self-regulation model of depression has been developed. It proposes that depression is maintained by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life goals. Depression is more difficult to treat when these processes become interlocked. Treatment based on the model builds self-regulation skills and restructures self-identity, rather than target negative beliefs. A bespoke therapy plan is formed out of ten treatment components, based on an individual case formulation. Conclusions: A self-regulation model of depression is proposed that integrates theory, evidence and practice within the field of CBT. It has been developed with difficult-to-treat cases as its primary purpose. A case example is described in a concurrent article (Barton et al., 2022) and further empirical tests are on-going.

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“…The resulting model is an integrated CBT approach. More information about the model development is available in Barton and Armstrong (2019).…”

Section: Introductionmentioning

confidence: 99%

“…A concurrent article provides a case example of how the model is used in practice, and readers are encouraged to refer to that article to explore the therapeutic applications (Barton et al, 2022). The current evidence base is summarised in Barton and Armstrong (2019).…”

Section: Introductionmentioning

confidence: 99%

CBT for difficult-to-treat depression: self-regulation model

Barton

Armstrong

Robinson

et al. 2023

Behav. Cogn. Psychother.

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“…He requested further therapy to address the conflictual relationship with his father, and this article describes a subsequent long-term course of CBT that used a trauma focus to address this. In David's case, an individualised formulation was developed using the self-regulation model of depression (Barton and Armstrong, 2019;Barton et al, 2022;Barton et al, 2023). This sought to explain how historical trauma contributed to the triggering and maintenance of David's depressive episodes, through its impact on his self-identity.…”

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confidence: 99%

Recurrent depression and relational trauma: a single case of memory processing

Barton,

Armstrong,

Meares

et al. 2024

tCBT

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Cognitive behavioural therapy (CBT) is an effective treatment for depression, but a significant minority of clients are difficult to treat, including those with histories of relational trauma. The model of Beck et al. (1979) proposes that adverse childhood experiences lead to negative core beliefs, and these create a susceptibility to depression. However, Beck’s model does not identify trauma as a subset of adverse experiences. An alternative view is that traumatised clients internalise conflicting representations of self and it is conflict, interacting with trauma memories, that creates a vulnerability for depression. In this formulation, methods from the treatment of post-traumatic stress disorder (PTSD) could be incorporated into the treatment of depression, to emotionally process trauma memories and resolve self-identity conflicts. The aims of this study were to: (1) report the treatment of a 67-year-old man with recurrent depression and a history of prolonged relational trauma, and (2) to explore how memory processing from the treatment of PTSD can be incorporated into the treatment of recurrent depression. A single case observational design was used in the long-term treatment of a depressed traumatised client. The client received 47 individual sessions over 19 months in routine clinical practice in a tertiary CBT service. He completed repeated measures of mood, memory intrusions and sleep disruption. The client responded well to treatment with clinically significant improvements across measures of mood, memory and sleep. The effects were sustained over an 18-month follow-up. Memory processing was successfully integrated into a high-intensity treatment for recurrent depression. This is a promising approach for depressed clients with histories of relational trauma. Key learning aims (1) To consider how imaginal reliving can be incorporated into CBT for recurrent depression, when relational trauma is present. (2) To consider the cognitive processing mode of depressed traumatised clients when appraising beliefs about self and others. (3) To consider vulnerability to depression based on intrusive memories and conflicting self-representations, not only core beliefs.

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CBT for difficult-to-treat depression: single complex case

Barton

Armstrong²,

Holland³

et al. 2022

tCBT

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Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients are difficult to treat: they are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk, and are prone to drop out, non-response or relapse. CBT based on a self-regulation model (SR-CBT) has been developed for this client group which incorporates aspects of first, second and third wave therapies. The model and treatment components are described in a concurrent article (Barton et al., 2022). The aims of this study were: (1) to illustrate the application of high dose SR-CBT in a difficult-to-treat case, including treatment decisions, therapy process and outcomes, and (2) to highlight the similarities and differences between SR-CBT and standard CBT models. A single case quasi-experimental design was used with a depressed client who was an active participant in treatment decisions, data collection and interpretation. The client had highly recurrent depression with atypical features and had received several psychological therapies prior to receiving SR-CBT, including standard CBT. The client responded well to SR-CBT over a 10-month acute phase: compared with baseline, her moods were less severe and less reactive to setbacks and challenges. Over a 15-month maintenance phase, with approximately monthly booster sessions, the client maintained these gains and further stabilized her mood. High dose SR-CBT was effective in treating depression in a client who had not received lasting benefit from standard CBT and other therapies. An extended maintenance phase had a stabilizing effect and the client did not relapse. Further empirical studies are underway to replicate these results. Key learning aims (1) To find out similarities and differences between self-regulation CBT and other CBT models; (2) To discover how self-regulation CBT treatment components are delivered in a bespoke way, based on the needs of the individual case; (3) To consider the advantages of using single case methods in routine clinical practice, particularly with difficult-to-treat cases.

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CBT for Depression: An Integrated Approach

Cited by 4 publications

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CBT for difficult-to-treat depression: self-regulation model

CBT for difficult-to-treat depression: self-regulation model

Recurrent depression and relational trauma: a single case of memory processing

CBT for difficult-to-treat depression: single complex case

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