Cognitive Behaviour Therapy
with Older People
Trea Simpson
What is Cognitive Behaviour
Therapy?
What does the therapy aim to do?
What sort of interventions does it use?
How long does it last?
What does a CBT session look and sound like?- What
are it’s characteristics?
Cognitive Behaviour Therapy
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A short term, structured form of therapy
which
provides patients with a rationale for
understanding their problems
A vocabulary for expressing themselves and
Training in techniques for surmounting
distressing affective states and solving
problems
How does it work?
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Different types of CBT- but all work focus on
problematic patterns of thinking and behaviour.
Misinterpreting situations undermines how people
cope and behavioural responses serve to maintain
and exacerbate problems.
CBT aims to break this cycle by encouraging people
to re-examine their thinking. Beliefs are a hypothesis
to be tested. The therapist helps the client to
explore alternative interpretations using cognitive
and behavioural techniques.
Cognitive Model of Emotional Disorders
Padesky and Greenberger, 1996
Environment
Thoughts
Behaviour
Emotion
Biology
Characteristics
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Agenda
Problem oriented
Ahistorical
Scientific
Homeworks
Collaborative
Active and directive
Socratic questioning
Openness
How long does it take?
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Usually consists of weekly sessions
Typical course consists of eight to twelve
sessions- though this changes depending on
the condition.
1 single 3 hour session for phobias
Years for BPD.
Cognitive theory
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Based on an information processing
perspective.
Beck states that information processing bias
are present in all psychopathological states.
(Beck 1967, 1976, 1987)
The faulty information processing is part of
the complex symptom profile that serve to
maintain the disorder.
Schema
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A cognitive structure
Content of schema is considered important
for emotional disorders
2 types of informational content in Beck’s
theory
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Beliefs: core constructs, absolute in nature taken
as truths e.g “I’m vulnerable”
Assumptions: conditional, they are contingencies
between events and self appraisals e.g. “having a
bad thought means I’m a bad person”
Learning experience
Danger schema
formed (beliefs/
assumptions)
Critical incident
Schema activated
Negative Automatic Thoughts
Anxiety symptoms
Behavioural responses
Cognitive biases
Generic
model of anxiety
disorder
Empirical support for the model 1
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The classification system DSM IV has to identify those symptoms
that are specific to the disorder. Cognitive symptoms of worrying
and apprehension expectation are detailed as symptoms of GAD
and PD respectively.
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A cognition check list (CCL) can differentiate between people
with problems of depression, and panic- generalised anxiety is
less easy to discriminate from depression (Clark, Beck & Beck
1994).
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Wells (1997) cites a number of studies where patients with
anxiety report thoughts and visual fantasies concerning danger
(death disease and social humiliation).
Think of an occasion when you were
anxious- balloon experiment.
Beck’s Cognitive Theory of Depression
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Negative Automatic Thoughts
Systematic Logical thinking errors
Depressogenic schemata
Beck’s Theory of Depression
Early experiences
Core beliefs
Dysfunctional Rules
Critical incident (and activation of assumptions)
Depressed mood
Problems
Behaviour
physiological
problems
Negative
Automatic
Thoughts
Measurement of Negative Thinking
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A number of scales have been developed to
measure negative thinking. These show
greater negative thinking in depressed people
compared with controls; and greater than
depressed people in remission. (Blackburn et
al 1986; Eaves and Rush 1984)
Empirical support
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Teasdale & Dent (1987)
Induced temporary depressed mood with
previously depressed and never depressed
groups.
Results- recovered depressed persons more
likely to recall negative adjectives endorsed
as self descriptive than never depressed
group.
Stressor – Schema content match
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People have specific vulnerabilities to
depression. Schema content can predict the
stressor likely to result in depression. 2
categories- Sociotropic (interpersonal) and
autonomous/ self criticism.
Nietzel & Harris 1990 (cited in Leahy 2004)
found a match between cognitive style and
congruent life event in depressed patients.
Also found that there were greater levels of
depression in the sociotropy group.
Efficacy of CBT for Anxiety and
Depression
Randomised Controlled Trials
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Clark et al used an RCT to compare cognitive therapy,
applied relaxation and imipramine in the treatment of
Panic disorder (n= 64).
Comparisons with waiting list showed all three
treatments were effective. Comparisons between
treatments showed: cognitive therapy was superior to
both applied relaxation and imipramine on most
measures.
After 3 months CT superior to AT and imipramine.
After 6 months CT= Imipramine but superior to RT.
After 15 months CT superior to RT and imipramine
RCT Two psychological Treatments for
Hyperchondriasis
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Clark et al 1998. N=48 randomly assigned to
CT or behavioural stress management
(BSM).
Both superior to waiting list control group.
CT < BSM on measures of hyperchondriasis
at mid treatment and post treatment.
RCT for PTSD
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Ehlers et al 2003.
N=97 (RTA survivors)
CT < self help in reducing symptoms of
PTSD, depression , anxiety and disability.
At follow up CT had fewer PTSD symptoms
than Self help.
6 year outcome of CBT of recurrent
depression.
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Fava et al (2004)
N=42 successfully treated with
antidepressants randomly assigned to CBT of
residual symptoms or clinical management.
In both groups antidepressants tapered then
discontinued.
CT resulted in 40% relapse
Clinical management 90% relapse
Efficacy of CBT
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The effectiveness of cognitive therapy for the
treatment of depression, anxiety, and an
extensive list of other disorders, is now well
supported by a large body of research.
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Results of have been shown to translate to
clinical practice. (Gillesphie et al 2002)
Efficacy of psychotherapy with Older
Adults
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Meta–analytic review
Robinson, Berman & Neimeyer 1990
Analysis of 58 studies
Overall effect size for treatment vs no
treatment is 0.73 (0.8= large, 0.5= moderate,
0.2= small)
All forms of psychotherapy more effective
than no treatment.
Outcome studies CBT
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Tend to be completed for late life depression.
See table- highlight that CBT is an effective
treatment for late life depression.
Obstacles
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A Freudian view that older people lack the
mental plasticity to change or benefit from
psychotherapy.
Knight (1996) argues that those who work in
the field tend to be more optimistic.
Myths and psychotherapy (Laidlaw et al
2003)
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You can’t teach an old dog new tricks.
It must terrible getting old.
Old people don’t want psychotherapy
Stages of CBT
1.
2.
3.
4.
5.
Assessment and Formulation
Socialisation
Treatment- symptom specific (Cognitive
techniques- eliciting and modifying Negative
Automatic Thoughts, Behavioural Techniquesactivity, behavioural experiments)
Treatment schema based (Behavioural
experiments, positive data logs)
Relapse Prevention (Blue prints)
Assessment and Formulation
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The main purpose of assessment is to
develop a formulation.
Formulation is a way to understand the
idiosyncratic nature of the persons difficulties
(Padesky and Greenberger 1995).
CBT formulation is suited to working with
older adults because it is individualised.
Additional considerations for older adults
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Cohort beliefs- shared beliefs and
experiences of a generation. (Niederehe
1992 stigma of mental illness)
Role Investment- the importance and
functions of roles carried or lost. (Champion
and Power 1995 noticed gender differences).
Considerations for older adults
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Socio cultural beliefs- the internalising or
rejection of beliefs about aging in the society
or culture in which older people live.
Intergenerational links- the stresses and
supports of important close relationships.
Thompson 1996 highlights relationship
strains can trigger depression. E.g.
differences in views on relationship.
Early experiences
Core beliefs
Activating event
Cohort beliefs
Intergenerational Linkages
Role investment
Sociocultural context
Dysfunctional Rules
Depressed mood
Problems
Behaviour
physiological
Health status
Negative
Treatment strategies cognitive
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Identification and modification of negative
automatic thoughts
Thinking biases.
Common age related NAT’s
Its just my age
I’m a failure
“If only” thinking
Treatment strategies cognitive cont..
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Strategies for modifying NAT’s
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Examining the evidence
The consequence of holding x belief
Putting someone else in my shoes
Reviewing past successful coping methods.
Treatment Strategies Behavioural
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Activity scheduling – the importance of
increasing activity levels.
Increase in pleasurable activities (this needs
to be realistic and possible).
Practical problem solving.
Relaxation training.
Anxiety
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King and Barrowclough (1991) showed 7/10
benefited from standard interventions of
anxiety.
Evidence in this area is impoverished.
Depression in Dementia.
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Teri et al reported two behavioural treatments
(one focussing on problem solving and 1
focussing on increasing pleasant events.)
Both were shown to have beneficial effects
for the person with dementia and their care
giver.
Memory Problems
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Information presented slowly
Mnemonic devices, (say it show it do it)
Folders/ files/ note books
Flip chart in sessions
Rehearse homework's in session
Tape sessions
Multi morbidity
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Communication with multi disciplinary team
e.g. medications, inadequate resources.
Internalised ageism
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Dispel some myths with recent research.
Books such as Aging: exploding the myths
WHO 1999
Story Telling
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Inclination to provide extensive details.
Set up ground rules once alliance is
established- permission to interrupt.
Provide frequent summaries.
References
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Beck, A.T. (1963) Thinking and depression: 1, Idiosyncratic content and cognitive
distortions. Archives of General Psychiatry. 9, 324-333
Beck, A.T. (1976) Cognitive therapy and the emotional disorders. New York.
International Universities Press.
Beck,A.T. ; Rush,A.J. ; Shaw,B.F. & Emery,G. (1979) Cognitive therapy of
depression. New York. Guilford Press.
Blackburn, I.M. & Twaddle, V. (1999) Cognitive therapy in action: A practitioner’s
casebook. London. Souvenir Press (Educational & Academic) Ltd.
Blackburn, I. M., Jones, S. Lewin, R. J. P. (1986) Cognitive style in depression.
British Journal of Clinical Psychology
Butler, G. & Mathews, A (1983). Cognitive process in anxiety. Advances in behaviour
therapy, 5, 51-62.
Butler, G. & Mathews, A. (1987) Anticipatory anxiety and risk perception. Cognitive
Therapy and research, 91, 551-565.
Clark, D.A., Beck, A. T. & Beck, J. (1994) Symptom differences in major depression,
dysthymia, panic disorder, and generalised anxiety disorder. American Journal of
Psychiatry, 151, 205-209.
Clark, D.A. & Steer, R.A (1996) Empirical status of the cognitive model of anxiety and
depression. In Salkovskis, P. M. Ed Frontiers of cognitive Therapy. New York. The
Guilford Press.
References
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Eccles, M., Mason, J. (2001) How to develop cost-conscious
guidelines. Health technology assessment.
Ingram, R.E. (1990) Depressive Cognition: models mechanisms and
methods. In Ingram, R.E. Ed. Contemporary psychological
approaches to depression: theory research and treatment. New
York: Plenum Press.
Mathews, A., Richards, A. & Eyesenk, M.W. (1989). The
interpretation of homophones related to threat in anxiety states.
Journal of Abnormal psychology, 98, 31-34.
Roth, A. & Fonagy, P. (1996) What works for whom? A critical
review of psychotherapy research. New York. Guilford Press.
Salkovskis,P.M. (Ed.) (1996) Frontiers of cognitive therapy. New
York. Guilford Press.
Teasdale, J. D. (1988) Cognitive Vulnerability to persistent
depression. Cognition and Emotion, 2- 247-74.
References- effectiveness
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Hollon, S. D., & Beck, A. T. (2004). Cognitive and cognitive behavioral therapies. In M. J. Lambert (Ed.), Bergin
and Garfield's Handbook of Psychotherapy and Behavior Change (pp. 447-492). New York: Wiley.
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Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive
therapy in depressed patients. Journal of Affective Disorders, 49(1), 59-72.
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Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy
versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting &
Clinical Psychology, 71(6), 1058-1067.
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Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. G. (1994). A
comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British
Journal of Psychiatry, 164, 759-769.
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Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psychological
treatments for hypochondriasis: A randomised controlled trial. British Journal of Psychiatry, 173, 218-225.
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Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., et al. (2003). A randomized
controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for
posttraumatic stress disorder.[see comment]. Archives of General Psychiatry, 60(10), 1024-1032.
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Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., & Grandi, S. (2004). Six-year outcome of cognitive
behavior therapy for prevention of recurrent depression. American Journal of Psychiatry, 161(10), 1872-1876.
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Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., et al. (2003). A randomized controlled
study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Archives
of General Psychiatry, 60(2), 145-152.
References- evidence for the model
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Leahy, R. (2004) Contemporary cognitive
Therapy: Theory Research and Practice.
London Guilford Press.
Teasdale, J. D., & Dent, J. (1987). Cognitive
vulnerability to depression: An investigation
of two hypotheses. British Journal of Clinical
Psychology. 26, 113-126.