Focusing on the here and now helps individuals become aware of their negative thoughts, acknowledge them without judgment and realize they’re not accurate reflections of reality, writes author William Marchand, M.D., in his comprehensive book Depression and Bipolar Disorder: Your Guide to Recovery. In it, Dr. Marchand recounts the benefits of mindfulness interventions and provides in-depth information about other psychotherapeutic and pharmacological treatments.

Through mindfulness, individuals start to see their thoughts as less powerful. These distorted thoughts – such as “I always make mistakes” or “I’m a horrible person” – start to hold less weight. In his book Marchand describes it as “watching ourselves think. We ‘experience’ thoughts and other sensations, but we aren’t carried away by them. We just watch them come and go.”

Mindfulness-based cognitive therapy (MBCT) is a group therapy that combines mindfulness principles with cognitive therapy to help prevent relapse in depression. It’s based on mindfulness-based stress reduction (MBSR), a program developed by Dr. Jon Kabat-Zinn. MBSR includes mindfulness tools, such as meditation, a body scan and hatha yoga, along with education about stress and assertiveness, according to Marchand. (Learn more here.)

MBCT teaches individuals to detach from distorted and negative thinking patterns, which can trigger the return of depression. (Learn more here.)

Studies have suggested that MBCT is a valuable intervention for depression. This recent meta-analysis found that MBCT was highly effective in reducing relapse for major depression. This study found that it was beneficial for individuals currently struggling with depression.

Getting professional treatment for depression is vital. But there are complementary mindfulness practices readers can try on their own. Marchand shared his suggestions below.

Mindfulness Meditation

“Mindfulness meditation is essentially training one’s attention to maintain focus and avoid mind wandering,” said Marchand, also a mindfulness-based cognitive therapy provider who practices meditation in the Soto Zen tradition. “Strengthening one’s ability to focus attention can help with concentration and memory.”

If you’re new to meditation, Marchand suggested carving out 10 to 15 minutes to meditate on most days. Specifically, “sit in a comfortable position and focus attention on the physical sensations of the breath.” Your mind will probably wander. That’s completely normal, he said. Simply refocus your attention back to your breath.

Psychotherapist and meditation teacher Tara Brach, Ph.D, has a number of guided meditations on her website.

Mindfulness in Daily Activities

Whether you’re eating, showering or getting dressed, you can practice mindfulness while doing any activity, according to Marchand, also a clinical associate professor of psychiatry at the University of Utah School of Medicine. The key is to focus on your physical sensations, such as “sight, taste, touch and smell.” Focus on the moment, instead of the past or future, he said.

Marchand suggested applying mindfulness to one activity every day. Again, you can be mindful with any task or action, such as brushing your teeth, having dessert or washing the dishes.

For instance, if you’re eating mindfully, minimize your distractions – such as watching TV or working on your computer – slow down your pace and pay attention to the taste, texture and aroma of your food.

Another option is to take a mindful walk, which also is helpful because it includes exercise, “an important component of healing.”

Mindfulness is a valuable practice for improving the cognitive symptoms of depression, such as distorted thinking and distractibility. It helps individuals recognize these more subtle symptoms, realize that thoughts are not facts and refocus their attention to the present.

Additional Resources

In his book, Marchand suggests additional self-help resources on mindfulness. These are:

Books by Jon Kabat-Zinn: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress; Coming to Our Senses: Healing Ourselves Through Mindfulness; and Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life.
The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness by Mark Williams, John Teasdale and Zindel Segal.

At the same time, therapists who practice CBT aim to help their patients change patterns of behavior that come from dysfunctional thinking. Negative thoughts and behavior predispose an individual to depression and make it nearly impossible to escape its downward spiral. When patterns of thought and behavior are changed, according to CBT practitioners and researchers, so is mood.

How Does Cognitive Behavioral Therapy Differ From Other Depression Treatments?
The focus and method of cognitive behavioral therapy sets it apart from other, more traditional therapies:

• CBT is based on two specific tasks: cognitive restructuring, in which the therapist and patient work together to change thinking patterns, and behavioral activation — in which patients learn to overcome obstacles to participating in enjoyable activities. CBT focuses on the immediate present: what and how a person thinks more than why a person thinks that way.
• CBT focuses on specific problems. In individual or group sessions, problem behaviors and problem thinking are identified, prioritized, and specifically addressed.
• CBT is goal oriented. Patients working with their therapists are asked to define goals for each session as well as longer-term goals. Longer-term goals may take several weeks or months to achieve. Some goals may even be targeted for completion after the sessions come to an end.
• The approach of CBT is educational. The therapist uses structured learning experiences that teach patients to monitor and write down their negative thoughts and mental images. The goal is to recognize how those ideas affect their mood, behavior, and physical condition. Therapists also teach important coping skills, such as problem solving and scheduling pleasurable experiences.
• CBT patients are expected to take an active role in their learning, in the session and between sessions. They are given homework assignments at each session — some of them graded in the beginning — and the assignment tasks are reviewed at the start of the next session.
• CBT employs multiple strategies, including Socratic questioning, role playing, imagery, guided discovery, and behavioral experiments.
• CBT is time limited. Typically, treatment with CBT lasts 14 to 16 weeks

Who Can Benefit From CBT?
Anyone with mild or moderate depression can potentially benefit from cognitive behavioral therapy, even without taking medication. A number of studies have shown CBT to be at least as effective as antidepressants in treating mild and moderate depression. Studies also show that a combination of antidepressants and CBT can be effective in treating major depression.

CBT can be an effective treatment for mild and moderate depression in adolescents as well. It’s also been shown to be effective at reducing relapses in patients who experience frequent relapses after having gone through other treatments.

Nearly two out of every three patients who are treated successfully for depression are treated with medications alone. Other patients, though, have lingering symptoms even when medication is partially working. CBT can be effectively used to treat many of these patients.

Although a wide range of people respond well to cognitive behavioral therapy, experts point out that the type of person likely to get the most benefit is someone who:

• is motivated
• has an internal locus of control
• has the capacity for introspection

What Is Cognitive Restructuring?
Cognitive restructuring refers to the process in CBT of identifying and changing inaccurate negative thoughts that contribute to the development of depression. This is done collaboratively between the patient and therapist, often in the form of a dialogue. For instance, a college student may have failed a math quiz and responded by saying, “That just proves I’m stupid.”

The therapist might ask if that’s really what the test means. In order to help the student recognize the inaccuracy of the response, the therapist could ask what the student’s overall grade is in math. If the student answers, “It’s a B,” the therapist can then point out that his answer shows he’s not stupid because he couldn’t be stupid and get a B. Then together they can explore ways to reframe what the performance on the quiz actually says.

The “I’m stupid” response is an example of an automatic thought. Patients with depression may have automatic thoughts in response to certain situations. They’re automatic in that they’re spontaneous, negative, and don’t come out of deliberate thinking or logic. These are often underpinned by a negative or dysfunctional assumption that is guiding the way patients view themselves, the situation, or the world around them.

Other examples of automatic thinking include:

• Always thinking the worst is going to happen. For instance, a person may convince himself he is about to lose his job because the boss didn’t talk to him that morning or he heard an unsubstantiated rumor that his department was going to cut back.
• Always putting the blame on oneself even when there is no involvement in something bad that happened. For example, if someone did not return your call, you might blame it on the fact that you are somehow a very unlikeable person.
• Exaggerating the negative aspects of something rather than the positive. Think of someone who exercises a stock option from a bonus a week before the stock rises another 10%. Instead of enjoying the bonus money he just got, he tells himself he never gets the breaks or that he’s too afraid to take risks that he should take. If he weren’t, he would have known to wait.

The idea in CBT is to learn to recognize those negative thoughts and find a healthier way to view the situation. The ultimate goal is to discover the underlying assumptions out of which those thoughts arise and evaluate them. Once the inaccuracy of the assumption becomes evident, the patient can replace that perspective with a more accurate one.

Between sessions, the patient may be asked to monitor and write down the negative thoughts in a journal and to evaluate the situation that called them up. The real goal is for the patient to learn how to do this on his or her own.

What Is Behavioral Activation?
Behavioral activation is another goal of CBT that aims to help patients engage more often in enjoyable activities and develop or enhance problem-solving skills.

Inertia is a major problem for people with depression. One major symptom of depression is loss of interest in things that were once found enjoyable. A person with depression stops doing things because he or she thinks it’s not worth the effort. But this only deepens the depression.

In CBT, the therapist helps the patient schedule enjoyable experiences, often with other people who can reinforce the enjoyment. Part of the process is looking at obstacles to taking part in that experience and deciding how to get past those obstacles by breaking the process down into smaller steps.

Patients are encouraged to keep a record of the experience, noting how he or she felt and what the specific circumstances were. If it didn’t go as planned, the patient is encouraged to explore why and what might be done to change it. By taking action that moves toward a positive solution and goal, the patient moves farther from the paralyzing inaction that locks him or her inside the depression.

Is There a Standard Procedure for Therapy Sessions?
Mental health professionals who practice CBT receive special training and follow a manual in their own practice. Although actual sessions may vary, they typically follow this outline:

• The session begins with a check on the patient’s mood and symptoms.
• Together, the patient and therapist set an agenda for the meeting.
• Once the agenda is set, they revisit the previous session so they can bridge to the new one.
• The therapist and patient review the homework assignment and discuss problems and successes.
• Next they turn to the issues on the agenda, which may or may not all get addressed.
• New homework is set.
• The session ends with the therapist summarizing the session and getting feedback from the patient.

A typical session lasts 50 minutes to an hour.

What Does It Mean to Say That Cognitive Behavioral Therapy Is Time-Limited?

Some other types of therapy are open ended in that there is no clear end date established. With CBT, the goal is to terminate therapy at a certain point, usually after 14 to 16 weeks.

It takes about eight weeks for the patient to become competent at the skills that are being taught in therapy and to reasonably understand the model. While this is going on, the patient usually experiences a significant reduction of symptoms. Between eight and 12 weeks patients often experience a remission of symptoms. During the remaining time, they continue to practice the skills learned and to address issues related to ending the sessions.

More severe cases of depression may take longer to resolve, but for most patients, 14 to 16 weeks with occasional sessions during the first year to reinforce the new skills is adequate.

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The current study compares the long term outcomes of CPT and PE for PTSD in female rape survivors. The original study measured symptoms of women suffering from PTSD (n=171), before and after receiving either CPT or PE. This long term follow up, from 4.5 to 10 years later (M = 6.15), includes 73.7% of the original sample following initial treatments (n= 126) of CPT (n= 63) or PE (n=63). Researchers used the PTSD Symptom Scale (PSS), the Beck Depression Inventory (BDI), and the Clinician-Administered PTSD Scale (CAPS) to measure PTSD symptoms. Of those allocated to CPT, 46 completed the therapy, 10 received some therapy, and 7 did not start. Of those allocated to PE, 44 completed the therapy, 13 received some therapy, and 6 did not start.

Participants who received both cognitive therapies (CPT and PE) showed significant improvements in PTSD and related symptoms from pre- to post-treatment. There was no marked significance in the difference between the two samples receiving treatment. During the long term follow up, there was an impressive amount of maintenance of these improvements in symptoms. At pre-treatment assessment, 100% of participants had met criteria for PTSD; however, at the long term follow up only 22.2% of participants in the CPT group and 17.5% in the PE group met criteria for PTSD. In addition, there was no further psychotherapy or medication use reported which could have otherwise accounted for the long term efficacy of these treatments.

Female rape survivors in this study benefitted significantly from a lasting improvement in PTSD symptoms. Although further research and replication studies are needed, these findings suggest that CBT may be effective for years following initial treatment.

Resick, Patricia A., Williams, Lauren F., Suvak, Michael K., Monson, Candice M., & Gradus, Jaimie L. (2012). Long-term outcomes of cognitive–behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of Consulting and Clinical Psychology, 80(2) 201-210.

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Beck Institute will offer a 3-day workshop on CBT for PTSD on September 10-12, 2012, in Philadelphia. A limited number of spaces remain.

(Posted September 4, 2012)
Healing PTSD: Emotional Processing with Cognitive Behavioral Therapy

Elizabeth A. Hembree, PhD
Department of Psychiatry, Perelman School of Medicine
University of Pennsylvania

Traumatic experiences are quite common, and survivors must in some way emotionally process and integrate these unwanted and painful events. Successful processing yields a realistic perspective in which the traumatic experience is in the past, reducing the person’s sense of current threat. Many trauma survivors accomplish this over time via natural mechanisms of recovery and do not require treatment. When this process is impeded or the natural processing is insufficient, posttraumatic stress disorder (PTSD), depression, and other problems frequently result.

Studies continue to show that PTSD is a common condition, with prevalence in the general US population of about 8%. Prevalence of PTSD in the active military and veteran population is even higher: Among US active duty service men and women returning from current military deployments, PTSD is estimated as high as 14-16% and among US veterans of the wars in Iraq and Afghanistan, estimates range from 4% to 17% (see Hoge et al., 2004; Richardson et al., 2010).

Given the impact of PTSD on individuals and families affected by this condition, dissemination and implementation of effective treatments is a very high priority.

Psychological treatments are aimed at helping the PTSD sufferer to process and integrate traumatic experiences. Cognitive behavioral therapies have extensive and strong empirical support and often result in remission or a decrease in the severity of PTSD, and decreased severity of depression and anxiety. All effective CBT interventions, which commonly include exposure (imaginal and in vivo), cognitive therapy, or skills training (e.g., stress inoculation; affect regulation and interpersonal effectiveness training), help the survivor to become less afraid of or threatened by trauma memories and reminders and of PTSD symptoms themselves, and to feel more competent and better able to cope. Theorists of exposure and cognitive approaches agree that treatment must in some way access or activate trauma memories, thoughts, and feelings, while providing corrective information that serves to modify the person’s unrealistic expectations of harm and danger and to reduce excessive negative emotion.

Prolonged exposure (PE; Foa, Hembree, Rothbaum, 2007) for PTSD has amassed considerable empirical support and is one of the primary treatments being rolled out by the U.S. Department of Veteran’s Affairs and the Department of Defense. While PE is a highly effective treatment, clinicians are sometimes concerned about whether it is an appropriate treatment for individuals with PTSD resulting from certain types of trauma or for those clients whose trauma narratives and current experience are dominated by emotions other than or in addition to fear: guilt, shame, anger, grief, and sadness. This is understandable – exposure-based treatments were designed for amelioration of excessive and/or unrealistic fear, not excessive guilt or anger. Experienced trauma therapists know that fear is but one of the emotional responses to trauma that are important to address in treatment. And most likely all would agree that facing trauma memories and reminders, and dealing with the feelings that result, are of prime importance.

Clinicians are also sometimes concerned that repeated revisiting of some trauma memories, particularly those associated with guilt or shame or anger about what occurred or what one did or did not do during the trauma, will be ineffective or will result in increased negative emotion. Many years of using and studying PE have yielded a rich understanding of emotional processing of traumatic memories via imaginal and in vivo exposure. Imaginal exposure – repeatedly revisiting trauma memories in imagination – and discussing and processing this experience with the therapist is a potent and efficient means of helping the PTSD sufferer to 1) fully access all of the salient information – facts, emotions, thoughts, behaviors, environment – within the trauma memory, 2) contextualize and understand his or her reactions and experience of the trauma and its aftermath, and 3) achieve a realistic perspective on the traumatic event and one’s behavior during it, as well as the impact it has had and will have in the future.

These outcomes are clearly illustrated in the case of a veteran treated with PE whose traumatic experience involved a deadly engagement with the enemy in which several of the men under his command were killed, despite his considerable and courageous efforts to lead this mission successfully and to save lives. The veteran presented for treatment about 5 years after this event with severe PTSD and depression, and he was suffering from extreme guilt and self-blame for the death of his men. In imaginal exposure he revisited the memory of that painful day in which these men under his command were killed and he was shot at while trying to render them aid. He was given a recording of this first imaginal exposure to take home and asked to listen to it daily before the next session, which he did.

During the review of his homework in the following session, the veteran reported that he had listened to the recording of his imaginal exposure frequently, as requested, and that he had done much ‘soul-searching’. He realized that he had done his job as best he could, and that if he had not done his job well, even more people would have died. Moreover, the veteran reported that thinking this over and listening to the session repeatedly had led him to accept that there was probably nothing that he could have done differently, and that he was beginning to feel a lessening of the “guilt and shame and the blame” he held on to for years after the death of his men. The veteran seemed relieved as he told his therapist that even though he had done everything in his power to bring everybody home, it was just not possible, and not up to him. He ended by saying that he was realizing through this process that he needed to try to let this go and to forgive himself.

This case is a good reminder that our powers of recovery are strong, and that when these powers have stalled or been impeded, they can be unleashed or facilitated by good, trauma-focused psychotherapy so that healing can proceed. Prolonged exposure and cognitive therapy, often primed by imaginal revisiting of the trauma memory as suggested by Ehlers and Clark (2000), are powerful and effective procedures that activate these forces and promote a reorganization of the trauma-related information that is more accurate and whole, an acceptance of what has happened, and a reduction of anxiety, guilt, anger, sadness, and other emotions that have dominated the person’s current experience, and result in reduction of PTSD and other trauma-related disorders.

References

Ehlers, A., & Clark, D.M. (2000). A Cognitive Model of Persistent Posttraumatic Stress Disorder. Behaviour Research and Therapy, 38, 319-345.

Foa, E. B., Hembree, E. A. & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. New York: Oxford University Press.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

Richardson, L. K., Frueh, B. C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.

(Posted July 10, 2012)

Often pain killers don’t improve a person’s ability to function well (because they feel too sedated) or their quality of life, which should be the main goal in treating pain.

Most pain experts advocate a more comprehensive approach to managing pain including exercise and what’s known as cognitive behavioral therapy (CBT).

CBT includes talk therapy to change the way you think about your pain as well as behavioral approaches that reduce stress, improve sleep and manage anxiety.

Now, a new study found that CBT is significantly more effective than standard care in treating people with body wide pain, like those with fibromyalgia. In the study, published in the January issue of the Archives of Internal Medicine, 442 patients with chronic body-wide pain, were randomized into one of four groups: one group received CBT over the phone; one group was  told to exercise 20 to 60 minutes a day, at least twice a week; one had CBT and exercise, and a control group that continued whatever treatments they were using.

In the group with the combined CBT and exercise intervention, 37 percent reported improvements in their general wellbeing after nine months, compared to only eight percent in the control group.  About 33 percent of those who only received CBT reported improvements and 24 percent of those who only exercised reported improvements.

CBT addresses factors that help reduce pain and help patients cope with pain symptoms. It’s short term therapy that can last as few as eight to 10 sessions. It includes a range of approaches including:

• Behavioral activation. The main objective is to increase your activity levels by participating in positive and rewarding activities. People in pain tend to avoid activities because of fears, anxiety or depression.

• Cognitive restructuring. This approach helps people identify unhelpful patterns of thinking and negative thoughts, replacing them with more constructive ways of thinking. So if someone is saying to herself, “I’ll never get better,” a therapist might try to get her to stop catastrophizing her situation and take a more day by day approach. If you show signs of depression, you may be referred to a medical doctor for an antidepressant prescription. Many people with chronic pain suffer from depression and depression is known to worsen the pain.

• Lifestyle changes. The therapist works with you to help improve your sleep (fatigue worsens pain) and teaches you relaxation techniques, which could include deep breathing, meditation or even biofeedback.  You’d also examine your diet and exercise habits. Exercise, though difficult I f you’re in pain, is one of the best ways to reduce your pain.
 

Laurie Tarkan is an award-winning health journalist whose work appears in the New York Times, among other national magazines and websites. She has authored several health books, including “Perfect Hormone Balance for Fertility.” Follow her on Twitter and Facebook.

Read more: http://www.foxnews.com/health/2012/01/17/cognitive-behavioral-therapy-reduces-pain/#ixzz27Ljs9x9A