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THERAPIST TECHNIQUE 1 Cognitive Behavioural Therapy for Major CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 1 Cognitive Behavioural Therapy for Major Depression: Identifying and Examining Core Therapist Techniques Amanda Sheptycki, M.A., Ph.D. (c) Department of Educational and Counselling Psychology McGill University, Montréal March 2020 A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Doctor in the Philosophy of Psychology. © Amanda Sheptycki 2020 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 2 Table of Contents Table of Contents……………………………………………………………………………….2 List of Tables and Figures……………………………………………………………………....5 Abstract…………………………………………………………………………………………7 Résumé………………………………………………………………………………………….9 Acknowledgements……………………………………………………………………………..11 Contributions to Original Knowledge………………………………………………………….12 Contribution of Authors………………………………………………………………………..13 Chapter 1. Introduction: Literature Review……………………………………………………14 Cognitive Behavioural Model of Major Depression…………………………………..17 Cognitive Behavioural Therapy Core Principles……………………………………...18 Therapist Technique in Cognitive Behaviour Therapy……………………………….20 Cognitive Restructuring Techniques………………………………….20 Definition and examples of techniques……………………………….20 Effects on patient outcome……………………………………………21 Criticisms and limitations of current research………………………..23 Behavioural Activation Techniques………………………………………….27 Definition and examples of techniques………………………………27 Effects on patient outcome…………………………………………..28 Criticisms and limitations of current research……………………….32 A Need for Future Research…………………………………………33 Research Objectives…………………………………………………40 References…………………………………………………………………………...41 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 3 Brief Overview……………………………………………………………………………....,,,,,52 Chapter 2. Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of Cognitive Interventions Targeting Automatic Thoughts in Major Depression………53 Abstract……………………………………………………………………………..…...55 Introduction……………………………………………………………………………...56 Method..……………………………………………………………………………........58 Results……………………………………...…………………………………………...61 Discussion……………….……………………………………………………………...79 References. ……………………………………………………………………………..82 Figures…………………………………………………………………………….........104 Appendices……………………………………………………………………………..105 Linking Manuscripts 1 and 2…………………………………………………………………..110 Chapter 3. Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of Cognitive Interventions Targeting Core Beliefs in Major Depression……………….111 Abstract…………………………………………………………………………….....113 Introduction…………………………………………………………………………...114 Method……………………………………………………………………………......116 Results……………………………………………………………………………......119 Discussion…………………………………………………………………………….128 References…………………………………………………………………………….132 Figures……………………………………………………………………………......153 Appendices…………………………………………………………………………...154 Linking Manuscripts 2 and 3………………………………………………………………...159 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 4 Chapter 4. Therapist Techniques in Cognitive Behavioural Therapy for Reduction of Depressive Symptomology: A Systematic Review of Cognitive Restructuring and Behavioural Activation Techniques…………………………………………….......160 Abstract……………………………………………………………………………..162 Introduction….…………………………………………………………...………...163 Method……………………………………………………………………………..167 Results……………………………………………………………………………..174 Discussion…………………………………………………………………………181 References…………………………………………………………………………187 Tables……………………………………………………………………………...196 Figures…………………………………………………………………………….209 Appendices………………………………………………………………………..211 Chapter 5 – General Discussion……………………………………………………….....224 Master Reference List……………………………………………………….……….......236 Appendix…………………………………………………………………………………265 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 5 List of Tables and Figures Chapter 2 Figure 1. Prisma Flow Diagram …………………....…..…….……………………….104 Appendix A. Embase Search Strategy.……………....…..…….……………………...105 Appendix B. Medline Search Strategy……………....…..…….……………………..107 Appendix C. PsycINFO Search Strategy……………....…..…….…………………...108 Chapter 3 Figure 1. Prisma Flow Diagram ……....…..…….…………………………………….153 Appendix A. Embase Search Strategy……....…..…….………………………………154 Appendix B. Medline Search Strategy……....…..…….……………………………..156 Appendix C. PsycINFO Search Strategy ……....…..…….………….……………….157 Chapter 4 Table 1. Quality Assessment of Included Studies…………………………………….196 Table 2. Characteristics of Individual Study Designs…………………………..…….198 Table 3. Cognitive Interventions versus Control………………………..……………200 Table 4. Cognitive Interventions versus Cognitive-behavioural Interventions………201 Table 5. Cognitive Interventions versus Behavioural Interventions…………………202 Table 6. Behavioural Interventions versus Control…………………………………..203 Table 7. Behavioural Interventions versus Cognitive-behavioural Interventions……205 Table 8. Behavioural Intervention versus Third-wave Intervention………………….206 Table 9. Clinical Significance of Interventions Delivered Individual Therapy………207 Table 10. Clinical Significance of Interventions Delivered Group Therapy…………208 Figure 1. Prisma Flow Diagram Original Search…………………………………….209 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 6 Figure 2. Funnel Plot of Cognitive Interventions versus Control……………………210 Appendix A. Embase Search Strategy Original and Updated Search……....…..…...211 Appendix B. Medline Search Strategy Original and Updated Search……....…..…...216 Appendix C. PsycINFO Search Strategy Original and Updated Search……....…..…220 Supplemental Material Appendix A. Data extraction of scoping review……………………………………..265 Appendix B. Therapist techniques targeting automatic thoughts……………………282 Appendix C. Therapist techniques targeting core beliefs……………………………284 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 7 Abstract Major depression is a leading cause of disability and early death (Lam, et al., 2016). Among the various psychotherapy treatments available, Cognitive Behavioural Therapy (CBT) is recommended as a first-line treatment for depression, and behavioural activation alone is recommended as a second-line therapy (National Institute for Health and Clinical Excellence [NICE], 2018). CBT is an integrative treatment that incorporates many therapeutic techniques, including the core techniques of cognitive restructuring and behaviour activation (Beck & Beck, 2011; Friedberg & Brelsford, 2011; O’Donohue & Fisher, 2012). Research appears to demonstrate conflicting results regarding the importance of both types of interventions in the treatment of depression (Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al., 2009). Given this, and given the extensive literature base on CBT and more specifically on cognitive interventions and behavior activation interventions, a next step would be to review the available literature. This manuscript-based thesis includes three studies related to therapist technique within CBT. The overarching purpose of this research endeavor is to better understand therapist technique in CBT through exploring and summarizing information on therapist techniques and through examining how these techniques impact symptomology in major depression. Kanter and colleagues (2010) conducted a review on behavioural activation techniques and unearthed a comprehensive typology and definition for each individual type, and summarized information regarding the optimal application of each technique. With regards to more cognitively focused interventions, there are extensive studies, and clinical resources on these therapeutic strategies as well; however, a comprehensive review similar to the one conducted by Kanter and colleagues does not appear to be readily available. The first two manuscripts address this gap and include a scoping review on cognitive interventions; given the vast literature, the cognitive restructuring CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 8 review was separated into two manuscripts. Manuscript one examines cognitive techniques aimed at automatic thoughts, while manuscript two examines cognitive techniques that targeted core beliefs. In manuscript one, three overarching types of cognitive intervention were identified including: (1) identifying techniques, (2) exploring techniques, and (3) challenging or modifying techniques. Clinical recommendations related to the suggested effective delivery for these cognitive interventions were also extracted and summarized. In manuscript two, core belief techniques were identified and described including: (1) identifying techniques and (2) modifying techniques. This manuscript also identified recommendations across records that pertained to the delivery of the intervention in a clinical setting. In both manuscripts, clinical and research implications are suggested. In manuscript three, the aim was to conduct a systematic review of the studies that dismantled CBT into its components or techniques. The review compared cognitive interventions and behaviour activation interventions to comparators including combined cognitive-behavioural interventions, third wave interventions and controls. Given that meta-analyses and systematic reviews have been conducted, the review narrowed in on randomized control trials of interventions delivered individually and in a group context, for adults diagnosed with major depression and also explored the interventions impact on level of depression. Results indicated cognitive and behavioural interventions did not significantly differ, and highlighted the need for future studies that dismantle interventions
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