MODULE 6 – COGNITIVE BEHAVIOR THERAPY IN PSYCHOLOGICAL DISORDERS

1. ACCEPTANCE AND COMMITMENT THERAPY (ACT)

ACT FOR DEPRESSION

Acceptance and Commitment Therapy (ACT) is a talk therapy for treating symptoms of
depression. ACT for Depression (ACT-D) helps individuals with depression make changes so that
they can have full, rich, and meaningful lives. The focus in ACT-D is to help you live more closely
to your values. It also helps you to be more accepting of yourself. ACT-D helps individuals to
have better relationships with themselves, others, and the world. Individuals learn to identify
and engage in activities that are in line with what they care about. By participating in ACT-D, the
individual learns to:
A = Accept     C = Choose     T = Take Action
Research has shown ACT-D to be effective for the treatment of depression. Program evaluation
data show that Veterans who have completed treatment had a significant decrease in
depression, improved awareness, and a better quality of life. ACT-D usually requires 10 to 16
individual sessions, but may take more or less time depending on the goals you set for
treatment.
By participating in ACT-D, you will learn to:
 Be more present to the "here-and-now." This focus helps to decrease being caught up in
what happened in the past. It also frees individuals from worrying too much about the
future. Being present helps you to more fully connect to and enjoy the moment.
 Observe thoughts and feelings in such a way that they no longer keep you stuck in life.
Learning to observe through openness and acceptance can help you find freedom from
negative thoughts and feelings.
 Clarify your values and then take action. Finding what is most meaningful to you and
choosing to act on these values are important parts of the therapy. This will be part of
the process of building a rich and full life.

ACT FOR ANXIETY

The approach focuses — as the name implies — on acceptance. The theory suggests that
increasing acceptance of your circumstance, the thoughts constantly running through your
mind, and your struggle with symptoms can lead to increased psychological flexibility.
Acceptance is theorized to protect against the avoidance of certain thoughts
or emotional experiences and ineffective coping.

Overall, this type of therapy encourages gaining insight into patterns of thinking, patterns of
avoidance, and the presence or absence of action that is in line with chosen life values.

The main components of ACT are psycho-education about the key mechanisms of the treatment
theory, mindfulness, cognitive defusion, and values clarification.

Sessions can include the practice of mindfulness exercises designed to foster nonjudgmental,

healthy awareness of thoughts, feelings, sensations, and memories that have otherwise been
avoided. Once the content of your innermost experience is identified, the therapist uses
discussion and cognitive exercises to help you recontextualize or make different sense of the
narrative and then accept it as your personal experience. To the extent that your actions are
inconsistent with your personal values of what makes for a meaningful life, the therapist will
help highlight discrepancies and engage you in a conversation about your values and the actions
that might move you closer to them.

ACT therapists may assign homework to practice between sessions, such as mindfulness,
cognitive, or values clarification exercises. The homework is agreed upon between you and your
therapist and can be modified to make it as personal and useful as possible.

2. DIAELECTICAL BEHAVIOR THERAPY (DBT)

DBT IN DEPRESSION
The goal of Dialectical Behavior Therapy in treating depression, as well as other psychiatric
disorders, is to teach skills that help you deal with day-to-day life. The group treatments are
designed to help you resolve crises in more effective and functional ways.

Therapists trained in Dialectical Behavior Therapy offer crisis intervention as a critical part of

depression treatment. As you begin to incorporate these DBT skills more frequently, you’ll find
that conflicts and crises are more manageable. By learning tangible skills to help you effectively
manage your emotions, deal with others, and manage crises, you may notice that your
depression symptoms decrease, since these are issues that typically contribute to depression.

Dialectical Behavior Therapy has proven to be effective for treating many of the symptoms of
depression, including the following:
 Difficulty concentrating, thinking, or remembering
 Persistent sadness or irritation
 Lack of interest in once-pleasurable activities
 Recurring thoughts of suicide or death
 Headaches, chronic pain, or other physical problems that don’t respond to treatment
The use of DIARY CARDS is a major component of DBT, one that could prove invaluable for treating
symptoms of depression. Diary cards are used by patients to keep track of the invalidating thoughts and
behaviors that affect them the most, but they can also be used to record what coping mechanisms are
effective. 

Patients are encouraged to keep their diary cards with them at all times and bring them to their therapy
sessions so they can receive feedback from therapists and other patients. Once again, it’s another useful
tool that works for treating borderline personality disorder and depression.

DBT IN ANXIETY
Emotions serve important functions in our lives. Primary emotions linked to anxiety, such as
fear, can at times make perfect sense - when there is a threat to our life, health, or well-being,
fear can motivate us to act and protect ourselves. At times, however, emotions like fear arise
when they are not helpful or productive. These emotions can be difficult to cope with and
manage, leading to anxiety and distress. 
DBT works through the process of learning emotional and cognitive skills (acquisition), and
subsequently applying those skills to your life (generalization). Generally, DBT tackles difficult
and distressing emotions and it can help you improve your capacity for emotional regulation,
that is, your ability to control the emotions you have, when you have them, and how you
experience and express them.
Through the DBT skills training group, clients learn skills such as mindfulness and distress
tolerance techniques that aid in being able to accept the present moment with willingness,
rather than fighting reality. These techniques could include breathing exercises, counting to ten,
or holding an ice cube in order to bring awareness and acceptance to the present. Exercises like
this encourage us to choose to accept what is happening in the moment.

Changing and influencing emotions is a central goal of DBT, but before you can get to this step it
is critical to understand and know where these emotions are coming from and why they arise.
The "understanding and acknowledging" step of DBT is one of the main facets that separates it
from regular CBT: this approach supports the mindful and non-judgmental observation and
description of emotional experiences. The addition of this aspect makes DBT effective across a
range of mental health problems, including anxiety disorders, because the skills you learn help
you differentiate emotions from facts, allowing you to work with and manage emotions
effectively.

3. MINDFULNESS BASED COGNITIVE THERAPY (MBCT)

MBCT IN DEPRESSION
When first devised, there was concern that intensity of negative thinking and difficulties
concentrating would prevent patients with active depression from fully benefiting from
MBCT.23 However, other researchers have explored MBCT for treatment of active depression.
In part, this has been based on metacognitive awareness, which MBCT teaches so well, being
postulated as an active component of CBT,7 and CBT has a rich literature supporting its use in
active depression.31 The first pilot study32 to examine MBCT as a therapy for the active phase
of recurrent depression reported a clinically meaningful improvement in BDI scores at 3 months
after completing a course of therapy (reduced from a mean score of 36 to 18), a comparable
improvement in anxiety scores, and a high degree of patient tolerability. In another small pilot
study33 of subjects with substantial residual symptoms between acute episodes of depression,
MBCT resulted in a significant improvement in BDI scores, and a strong trend for improvement
in rumination symptoms. In a particularly noteworthy study,34 when MBCT was compared
directly with CBT in a sample of currently depressed subjects, there was a substantial drop in
BDI of both groups that persisted at 12 months following therapy (with CBT, BDI scores dropped
from 36 to 19, whereas with MBCT scores dropped from 32 to 19). Of note, MBCT was equally
effective for people with fewer than 3 episodes in this study.

MBCT IN ANXIETY
There is strong theoretical rational for the application of MBCT to anxiety. As worry is by nature
future-oriented and involves avoidance of undesired outcomes, training in present-moment
awareness may provide an alternate way of being with worry and anxiety.43 There have been
some early trials of MBSR in anxiety disorders44 but only recently has MBCT specifically been
adapted for anxiety disorders, with the psychoeducational portion being modified to the target
population. A small initial pilot study45 showed significant improvements in multiple measures
of worry and anxiety, with 5 of 12 subjects improving from moderate-to-severe scores to
minimal on the Beck Anxiety Inventory. Another study46 of MBCT in subjects with persistent
symptoms of GAD or panic after at least 6 months of pharmacotherapy, reported significant
improvements in measures of anxiety, rumination, worry, and sleep quality. The single
controlled study47 of MBCT for patients with panic or GAD who had completed at least 6
months of prior pharmacotherapy compared MBCT to an anxiety education program. There
were significant improvements in anxiety measurers in the treatment group, with a substantial
number achieving remission, while there were minimal changes in the psychoeducation group.
 4. INTERPERSONAL THERAPY (IPT)

IPT IN DEPRESSION
Interpersonal therapy, or IPT, is a short-term, focused treatment for depression. Studies have shown
that IPT, which addresses interpersonal issues, may be at least as effective as short-term treatment
with antidepressants for mild to moderate forms of clinical depression. Originally developed to
treat depression in adults, it has been shown to be effective in treating adolescent depression and is
commonly recommended as a treatment for depression in children.
Events surrounding interpersonal relationships do not cause depression. But depression occurs
within an interpersonal context and affects relationships and the roles of people within
those relationships. By addressing interpersonal issues, interpersonal therapy for depression puts
emphasis on the way symptoms are related to a person's relationships, including family and peers.
The immediate goals of treatment are rapid symptom reduction and improved social adjustment.
The long-term goal is to enable people with depression to make their own needed adjustments.
When they can do that, they are better able to cope with and reduce depressive symptoms.

Feelings of depression often follow a major change in your life. These changes fall into one of
four categories:

 complicated bereavement — the death of a loved one or unresolved grief

 role transition — the beginning or ending of a relationship or marriage or diagnosis of a
disease
 role dispute — a struggle in a relationship
 interpersonal deficit — the absence of a major life event

IPT IN ANXIETY
No material is available

5. SOLUTION FOCUSED THERAPY

SFT IN DEPRESSION
When SFBT is used to treat depression, your therapist will help you set goals that will help you
achieve the future that you imagine. Your therapist will begin by asking a series of questions.
These questions will help you determine what is truly important to you that you’ll be motivated
to work towards achieving it.

For example, your therapist may ask you, "If you start your life free of depression on Monday
morning, how will things be different?" Your response to that question will help the therapist
determine appropriate goals for you, as well as what matters to you enough to motivate you to
be successful. Your response may be something simple, but it seems unattainable to you. If
you’re like many individuals, it will be something that you’ve had or felt in the past – before
your depression interfered with your ability to participate in normal everyday activities or to
gain joy from your experiences.
This process will also make you realize that there are actually positive things in your life – things
that you might not be aware of. You see, when you suffer from depression it’s very easy to focus
on all the negative things in your life – all the things that are wrong with it. You may feel
insecure and incompetent, and have little hope of ever enjoying a future free from your
depression.

However, Solutions focused therapy will help you have those "aha" moments when you being to
recognize these successes. As a result, you’ll start to gain confidence and feel even more
motivated (and confident) to move forward. Once you begin to recognize the many positive
things in your life, you can use them to help you attain future goals.

SFT IN ANXIETY
Solution-focused therapy offers practical ways you can focus on solutions rather than anxiety in
order to regain control of your life.
1. Take the Miracle Question seriously.
That’s the starting point. Peek back at the questions above. Take time to fully ponder them and
write out the answers. Think of them not as some supernatural miracle but as life goals.
2. Think of anxiety as an “it.”
Anxiety isn't you. It’s just an inanimate thing external to you and unwelcome. When you remove
it from your concept of “you,” you see the truth that it isn't who you are. Instead, it’s an object
that can be removed. You can take out the trash.
3. Look for positive exceptions.
Yeah, anxiety can feel pretty severe, all-encompassing, and debilitating. But take some time to
ponder your life. Despite how it may feel, no one feels intense anxiety 100% of the time. When
are those times that you don’t experience anxiety (or, at least, when is it a bit less intense)? Find
patterns.
4. Focus on new behaviors rather than merely stopping the old ones.
Rather than just saying you want to get rid of anxiety, concentrate on replacing it with
something else.
5. Use scales.
Scaling is a common tool in solution-focused therapy. Ask yourself: On a scale from one to ten
(with ten being the most severe), how severe is my anxiety right now? Then, ask yourself what it
would be like for you to move down the scale just one single number. Next, know that the
movement is in your control. What can you do to move down that one step?
Solution-focused therapy helps you shift your focus away from your anxiety away from what is
wrong to what is already right. Then you build on the “already rights” to make things even
“righter.” It takes work, but that’s part of the process of reclaiming control over your life.