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 further into individual techniques. Research and clinical implications for all manuscripts are identified and discussed.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 9

Résumé

La dépression majeure est l’une des principales causes d’invalidité et de mort prématurée (Lam, et al., 2016). Parmi les traitements psychologiques, la thérapie cognitive-comportementale (TCC) est recommandée comme traitement de première intention, alors que l’activation comportementale (AC) seule est recommandée comme thérapie de deuxième intention (National

Institute for Health and Clinical Excellence [NICE], 2018). La TCC est un traitement intégratif qui comprend de nombreuses techniques incluant les techniques de base telles que la restructuration cognitive (RC) et l’AC (Beck & Beck, 2011; Friedberg & Brelsford, 2011;

O’Donohue & Fisher, 2012). Cependant, la recherche semble démontrer des résultats contradictoires concernant l’importance de ces deux techniques de base (Cuijpers et al., 2007;

Ekers et al., 2008 Mazzucchelli et al., 2009). Compte tenu de cela et de l’abondance de la littérature portant sur la TCC, les interventions de RC, et les interventions d’AC, une prochaine

étape serait d’analyser la littérature disponible. Ce manuscrit de thèse comprend trois études liées

à la technique du thérapeute de la TCC. L’objectif primordial de cette initiative est d’explorer et synthétiser les informations portant sur les techniques du thérapeute afin de mieux comprendre l’effet de ces techniques sur la symptomatologie dans la dépression majeure. Kanter et al. (2010) ont effectué une analyse des différentes techniques d’AC et ont émis une typologie et une définition complètes, ainsi qu’une synthèse de l’informations concernant l’application optimale de chaque technique. En ce qui concerne les interventions de RC, et malgré la panoplie d’études et de ressources cliniques, une revue approfondie semblable à celle de Kanter et al. ne semble pas disponible. Les deux premiers manuscrits de thèse comblent cette lacune et incluent une revue de la portée des interventions cognitives. L’abondance de la littérature à justifier l’élaboration d’un premier manuscrit qui examine la RC visant la pensée automatique, et d’un CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 10 deuxième qui examine la RC qui cible les convictions fondamentales. Le premier manuscrit identifie trois principaux types d’intervention cognitive : (1) les techniques d’identification, (2) les techniques d’exploration, et (3) les techniques de contestation ou de modification. Des recommandations cliniques liées à la prestation efficace suggérée de ces interventions cognitives ont également été extraites et résumées. Le deuxième manuscrit identifie et décrit les principales techniques portant sur les convictions fondamentales, notamment : (1) les techniques d’identification et (2) les techniques de modification. Ce manuscrit identifie également des recommandations concernant la prestation de l’intervention en milieu clinique. Dans les deux manuscrits, des implications cliniques et de recherche sont suggérées. Dans le troisième manuscrit, l’objectif était de mener une revue systématique des études qui ont démantelé la TCC en ses composantes ou techniques. La revue compare les interventions de RC et les interventions d’AC à des comparateurs, y compris les interventions combinées cognitive-comportementales, les interventions de troisième vague et des conditions contrôles. Étant donné que des méta- analyses et des revues systématiques ont été menées, la revue s’est limitée aux essais contrôlés randomisés des interventions livrées de façon individuelle et dans un contexte de groupe, pour les adultes diagnostiqués avec une dépression majeure et a également exploré l’impact des interventions sur le niveau de dépression. Les résultats indiquent que les interventions de RC et d’AC ne différaient pas de manière significative et mettent en évidence le besoin de mener d’autres études qui décomposeraient les interventions en techniques individuelles. La recherche et les implications cliniques pour tous les manuscrits sont identifiées et discutées.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 11

Acknowledgments

There are many people who have been a tremendous support through this journey of completing my Ph.D. I am extremely thankful to my supervisor Dr. Martin Drapeau. Dr.

Drapeau has been my mentor throughout my Master’s and Ph.D. He has assisted in my development as a true scientist-practitioner, and has given me a deeper appreciation for research.

I am grateful for his thorough feedback that has helped me to become a stronger writer and enhanced my critical thinking abilities.

I would like to thank Dr. Bassam Khoury for his support and expertise in the methodology used in my systematic review. I would also like to thank Dr. Marie-Hélène

Pennestri for her assistance during my research proposal and support as a member of my dissertation committee. I am very thankful to Ms. Emma Schmelefske for her constant support and strong work throughout the entirety of my research projects. Your willingness and knowledge base had an immense impact across projects.

I could not have completed my Ph.D. without the constant support of my family. My father, mother, stepmother, brother, sister and brother in law have helped me to persevere and have been so patient and understanding with my Ph.D. journey. Thank you to my father who inspired my pursuit of higher education.

Completing my Ph.D. has been done alongside my supportive peers and dear friends.

Jennifer, Adina, Sumin, Lisa and Samir, I am so grateful that I was able to go through the program with each of you, and I thank you for your encouragement and guidance along the way.

I am also extremely thankful to the faculty members who provided support in my development as a psychologist and the additional students who aided in my projects along the way.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 12

Contributions to Original Knowledge

All three manuscripts are considered original research. I am the first author on each manuscript as I was involved in all aspects of the dissertation, including contributions to the research proposal and design, selecting the data for inclusion, and analyzing and interpreting the data. Additionally, I completed the original drafts of each manuscript and incorporated feedback from reviewers and co-authors, and finally prepared the final draft of the dissertation for submission.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 13

Contributions of Co-authors

The three manuscripts included in this thesis are the original writing of the doctoral candidate. Amanda Sheptycki developed the research methodology in conjunction with her supervisor, Dr. Martin Drapeau and supervisory committee. She prepared all written components of the final dissertation and integrated the feedback from her dissertation committee and co- authors including: Ms. Emma Schmelefske, Ms. Imy Shenouda, and Ms. Michelle Azzi.

Dr. Martin Drapeau supervised the thesis, and provided guidance on all components and stages of the dissertation, including intellectual, methodological, statistical and editorial contributions. Dr. Drapeau played a significant role in the dissertation and especially provided expertise on the research topic and feedback on each manuscript.

Ms. Emily Kingsland provided assistance for the development and editing of the search strategy for each of the studies included in the dissertation. Ms. Emma Schmelefske contributed to all three studies, including intellectual, methodological, statistical and editorial contributions.

Emma particularly contributed to the systematic review as in integral contributor to methodological considerations and development of the statistical tables. Dr. Bassam Khoury made methodological, statistical and editorial contributions to the systematic review.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 14

Chapter 1 – Introductions: Literature Review and Research Aims

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 15

Introduction: Literature Review

Depression is a psychological disorder that has been found to be the leading cause of disability; it has been projected that it will increase in prevalence (World Health Organization,

2000). This specific disorder has been linked with high mortality rates and has been listed as one of the ten top causes of early death in Canada (Statistics Canada, 1999). Depression has numerous personal and economic costs and has been found to result in 27.2 lost workdays per year for those who struggle with this mood disorder (Kessler et al., 2006). Considering that depression has been evidenced to be the most prevalent psychiatric illness (Kleine-Budde et al.,

2013), with immense personal and economic costs, it is important to continue to research the most effective and efficient treatment of this disorder.

Cognitive Behaviour Therapy (CBT) is a therapeutic approach that focuses primarily on cognitions and behaviours in order to treat various psychological disorders, including Major

Depression (American Psychological Association, 2016; Longmore & Worrell, 2007). This approach has been thoroughly researched and is considered to be a treatment for Major

Depression that has solid scientific evidence in support of it (Butler, Chapman, Forman, & Beck,

2006). CBT contains a multitude of treatment strategies and techniques that are derived from the understandings of the etiology and symptomology of depression (Beck, 2005; Cutler, Goldyne,

Markowitz, Devlin, & Glick, 2004). These therapeutic techniques include both cognitive and behaviour focused tasks and strategies (Beck, 2005), and are consistently described within the core principles of CBT (Beck & Beck, 2011; Friedberg & Brelsford, 2011; O’Donohue & Fisher,

2012) and within treatment manuals (Kanter & Puspitasari, 2012; Leahy & Rego, 2012; Young,

Rygh, Weinberger, & Beck, 2001). Cognitive restructuring techniques are applied in order to target maladaptive thinking that is often present in patients struggling with Major Depression CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 16

(Young et al., 2001). Some cognitive restructuring techniques include the Socratic method, empirical hypothesis testing and logical analysis (Leahy & Rego, 2012), to name but a few.

Behavioural activation techniques are designed to assist in activating the patient through scheduled activities that are positively reinforcing (Manos, Kanter, & Busch, 2010). Behavioural activation techniques may for example include activity monitoring, activity scheduling and contingency management (Kanter & Puspitasari, 2012).

While many therapist techniques, including cognitive restructuring and behavioural activation, are described in detail within CBT theory and are identified as being central to the approach (Leahy & Rego, 2012; Overholser, 2011), there appears to be a gap between the theoretical understanding of specific therapist techniques and the effect these techniques have on patient outcome. For example, the Socratic method, a commonly employed cognitive restructuring strategy has been positioned as a cornerstone technique in CBT according to cognitive theorists; however the link between the theoretical underpinnings of this technique and how it leads to reduction in depression symptomology remains unclear (Clark & Egan, 2015).

Further, there is some variability in therapist techniques described within clinical tools such as

CBT manuals (Hopko, Lejuez, Ruggerio, & Eifert, 2003); these techniques are not often standardized or clearly delineated, such that is unclear what each one might entail. In addition to this, there remain inconsistencies in the literature surrounding the effects of cognitive restructuring techniques compared to other CBT techniques on patient outcome, including more simple techniques such as behavioural activation (e.g., Mazzucchelli, Kane, & Rees, 2009). In light of this, Martell and colleagues (2001) have argued that therapist technique within CBT is a particularly important area to study, as training in, and delivering complex cognitive techniques CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 17 can be more expensive and demanding than training in, and delivering behavioural activation techniques.

There is clearly a need for a review of the current theoretical and research understandings of therapist technique in CBT, both to make suggestions for future clinical studies and to inform the improvement of CBT. The purpose of this paper is therefore to explore the use of therapist technique within CBT, specifically introduce and discuss the techniques of cognitive restructuring and behavioural activation, review empirical studies related to each therapist technique and treatment outcome, outline criticisms and limitations of cognitive restructuring techniques and behavioural activation techniques, and highlight suggestions for research.

Cognitive Behavioural Therapy

Cognitive Behavioural Model of Major Depression

Beck (1963, 1967) developed the theoretical underpinnings for CBT through his early work that focused on observations of patients with Major Depression. He conceptualized depression as being related to maladaptive information processing (Wright, 2006). Beck introduced the cognitive triad as he noticed three common patterns in patients with depression.

These three ways of thinking pertained to how one viewed the world, themself, and the future.

Patients with depression were described as having an overly negative and distorted view within these realms. In terms of how one views their world, someone with depression might view their environment as overly negative. With regards to one’s view of the self, one may judge their self as overly harsh in a way that is inconsistent with reality. Lastly, in relation to how one views their future they might catastrophize or distort what is likely to come. Within CBT, Beck incorporated behavioural techniques to activate his patients, prevent avoidance and to counter helplessness (Wright, 2006). As the approach matured, behavioural techniques continued to CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 18 become more integral to CBT and behavioural methods became more important aspects of the approach (Clark, Beck, & Alford, 1999; Wright, Beck & Thase, 2003).

Within the delivery of CBT therapists apply an integrative model that utilizes multisystems for case conceptualization and for the planning of treatment (Wright, 2006; Wright,

Basco & Thase, 2006). Cognitions and behaviours are theorized to have a two-way relationship where both thoughts and behaviours each mutually influence the other: cognition can affect behaviour and behaviour can impact cognition. The conceptual underpinnings of the approach allow for the therapist to intervene on a behavioural or cognitive level. The therapist can apply a myriad of techniques to reduce depressive pathology.

Core Principles in Cognitive Behavioural Therapy

Theorists have described various core principles throughout the history and development of the approach. The principles and strategies delineated by researchers over decades have various overlapping, but also some differing components and descriptions (Beck, 1976, 1979;

Young, Weinberger, & Beck, 2001). O’Donohue and Fisher (2012) noted 13 core principles that included functional analysis and contingency management, skills training, exposure, relaxation, cognitive restructuring, problem solving, self-regulation, behavioural activation, social skills, emotional regulation, communication, positive psychology and acceptance. Beck and Beck

(2011) outline 10 important principles of CBT. The first principle discusses having a working understanding of the presenting problem using cognitive terminology on a case-by-case basis.

The second principle emphasizes the importance of a strong therapeutic relationship. The third principle outlines the importance of the patient and therapist working collaboratively and both actively participating. The fourth and fifth principle entail how CBT needs to be focused on working toward goals and the presenting problem, and centered on the present. The sixth CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 19 principle describes the educative nature of the approach that incorporates psychoeducation and relapse prevention. The seventh and eighth principles describe CBT as brief and structured, respectively. The ninth principle delineates important techniques applied that include identifying, examining and countering dysfunctional beliefs and cognitions. The tenth and final principle describes how the approach incorporates various techniques to modify cognitions, behaviors and feelings.

Friedberg and Brelsford (2011) have also established a number of core principles, processes and practices in CBT that differ from the previous descriptions. They outlined that an integral focus of CBT is developing a case conceptualization based on theory. Additional components included collaboration, guided discovery and the importance of the therapeutic alliance. The researchers describe how CBT incorporates modular components that are comprised of techniques implemented based on theory. Further core principles include transparency regarding the approach and working from an empirical basis. Within session the therapist sets an agenda, conducts check-ins regarding the patient’s mood, tracks progress using objective measures, assigns and reviews homework, summarizes and gathers feedback, and processes the sessions. Lastly, the therapist examines cognitive and emotional domains, and brings these domains together. Within the literature on principles there does not appear to be one universally accepted list of principles but each approach does incorporate similar elements and each discusses the use of therapeutic techniques.

Cognitive Restructuring Techniques and Behavioural Activation Techniques

The therapist techniques that will be focused on here are cognitive restructuring techniques and behavioural activation techniques. There are a number of therapist techniques that have been identified in the CBT literature and the two types of techniques that will be CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 20 explored in what follows do not cover the exhaustive list of CBT therapist techniques. Cognitive restructuring techniques and behavioural activation techniques were chosen as they consistently are considered to be core principles of CBT. Cognitive restructuring techniques and behavioural activation techniques address at least six principles in O’Donohue and Fisher (2012) model, three principles in Beck and Beck’s (2011) model, and six principles in Friedberg and Brelsford’s

(2011) model of CBT. Further, previous empirical studies have suggested there are some inconsistencies in our understanding of how these selected techniques relate to treatment outcome in patients who experience Major Depression (Cuijpers, Van Straten, & Warmerdam,

2007; Ekers, Richards, & Gilbody, 2008; Taylor & Marshall, 1977).

Therapist Technique in Cognitive Behaviour Therapy

Cognitive Restructuring Techniques

Definition and examples of techniques. Cognitive restructuring techniques refer to the techniques in CBT that target distorted thinking patterns in patients. These techniques are used to address cognitive distortions or automatic thoughts and the specific situations that evoke these biases. These techniques also assess the credibility of a cognition, and aim to modify these cognitive distortions or automatic thoughts (Leahy & Rego, 2012). Cognitive restructuring techniques aim to detect assumptions and rules that are often common among patients diagnosed with depression and to alter these assumptions to be more adaptive, flexible, and positive. There are numerous cognitive restructuring techniques that have been identified, such as logical analysis, empirical hypothesis testing, questioning, evaluating, challenging and modifying thoughts, self-monitoring and the Socratic method (Leahy & Rego, 2012; Rush, Beck, Kovacs,

Hollon, 1977; Young et al., 2001). CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 21

Effects on patient outcome. There have been a number of studies that have examined specific cognitive restructuring techniques and reduction in major depression at post-treatment.

Jarrett and Nelson (1987) completed a component analysis of cognitive restructuring techniques that are often administered within CBT. They identified three techniques delineated within

Beck’s approach to CBT. These techniques included self-monitoring, logical analysis, and hypothesis testing. Jarrett and Nelson aimed to better understand which techniques were associated with the effectiveness of the approach by exploring how the components were related to reduction in depressive symptomology. Comparisons were made between applying self- monitoring and logical analysis, self-monitoring and hypothesis testing, and all three components together. Results demonstrated that there were no differences when comparing logical analysis to hypothesis testing. However, when participants received either component with self-monitoring or all three components, they reported significantly fewer depressive symptoms at termination.

Jarrett and Nelson’s results demonstrate evidence of a relationship between the application of techniques targeting cognitions and reductions in depression symptomology. However, the study did not demonstrate differences in logical analysis and hypothesis testing, which may suggest that generally examining the thought may be more important than the specific technique applied.

Teasdale and Fennell (1982) investigated the differences between exploring compared to modifying thoughts in patients with moderate to severe depression. The study found that applying cognitive modification strategies were integral to the amelioration of depressive symptoms compared to techniques that were more exploratory. Persons and Burns (1985) also explored change in depression and found that symptoms appeared to be reduced related to a confluence of three factors. These factors included therapeutic interventions, relationship CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 22 variables, and patient characteristics, and accounted for 89% of the variance in mood improvements.

Clark and Egan (2015) reported that there has been limited research regarding the

Socratic method on change in belief, patient engagement, information retention, subjective distress, and development of skills. There have been some studies on competency of the therapist in relation to the Socratic method and studies related to guided discovery on treatment outcome.

Braun, Strunk, Sasso and Cooper (2015) examined the strategy of Socratic questioning in the treatment of depression. Patients received 16 weeks of Cognitive Therapy and depressive symptom change was assessed from session to session. Results indicated that within-patient

Socratic questioning related to significant change in symptoms of major depression. Braun and colleagues were able to provide preliminary evidence for the relationship between applying

Socratic questioning and the reduction in major depression.

Empirical studies have also examined cognitive restructuring techniques more generally in relation to reduction in depression at outcome. Peterson, Luborsky, and Seligman (1983) investigated a single case (N = 1) of cognitive restructuring in relation to mood changes. Through examining within session changes they found that restructured attributions of negative events was related to changes in mood. DeRubeis and colleagues (1990) found further evidence for cognitive restructuring techniques and depression. They found that early cognitive changes during CBT were related to changes in depression severity over the course of the second half of psychotherapy.

Clore and Gaynor (2006) more recently compared cognitive restructuring to supportive therapy. The cognitive restructuring component included fluency training aimed to increase positive self-statements and thought record training aimed at challenging negative thoughts. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 23

Supportive therapy was defined as providing support to the patient through discussing feelings and their awareness of their emotional experience. They examined university students who reported high levels of internalizing distress. In relation to outcome the researchers found that cognitive restructuring was associated with larger changes in both internalizing distress and positive thinking. Leahy and Rego (2012) reported that cognitive restructuring has been examined with most Axis I and Axis II disorders, including depression. Results have generally demonstrated that cognitive restructuring is an effective therapist technique in relation to outcome. However, when comparing with other techniques or components within the approach there appears to be less support for cognitive restructuring techniques. For example, Jacobson and colleagues (1996) completed a landmark study that was composed of a component analysis of CBT. Participants were randomized to one of three arms, which included full cognitive therapy (CT), behavior activation or automatic thoughts. The full CT group received manualized therapy that included the behavioural activation component, the automatic thought component and included techniques that targeted core beliefs. The behavioural activation group included techniques administered to detect behavioural problems and encourage or activate behaviours.

The automatic thoughts arm consisted of behavior activation with the addition of focusing on modifying dysfunctional thoughts. Participants with depression were examined at pre and post- treatment and there appeared to be no significant difference in depressive symptomology among the three groups. The study raised some questions as to whether the full application or specific techniques are central to patient outcome in CBT.

Criticisms and limitations of current research. Through reviewing the literature on therapist technique and patient outcome there appears to be a further need for research regarding the conceptualization of constructs and impact of techniques on outcome. Firstly, there appears CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 24 to be a discrepancy in the definitions of techniques and there is a lack of standardization of cognitive restructuring techniques. Although there are detailed descriptions of certain techniques, some techniques may need to be more clearly delineated. For instance, the use of questioning seems to be often explained as more of an umbrella term and there are limited articles that go into the specific subtypes of questions (James et al., 2010). Secondly, there appears to be a gap between theoretical understandings and descriptions of therapist techniques, and empirical studies examining technique with patient outcome. For example, cognitive theorists have prepared various manuals and descriptive articles on specific techniques argued to be important to the approach. Young and colleagues (2001) explain various techniques such as questioning and eliciting automatic thoughts; however, it often unclear how these specific techniques relate to patient outcome. Additionally, one of the more commonly described techniques in the literature appears to be the Socratic method. For example, Carey and Mullan (2004) completed a thorough review of the literature on this method and revealed the limited research on this technique. There are few studies that have indicated the association between applying the

Socratic method with patient outcome and fewer studies demonstrating the association with reduction in depression. Furthermore, when considering additional techniques such as self- monitoring and challenging thoughts, there are even fewer studies that investigate the importance of the technique to treatment outcome. Although techniques have been described within scholarly work, there appears to be a need for a more standardized conceptualization. Further, there is a noticeable gap in examining cognitive restructuring techniques in relation to outcome in the treatment of depression.

There have been reported inconsistences in the optimal timing of when to apply cognitive restructuring techniques within the treatment process. Beck, Rush, Shaw and Emery (1987) CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 25 suggest cognitive restructuring to be implemented early in the therapeutic process. For example, they suggest the incorporation of these techniques following the activities related to the development of the therapeutic alliance. In contrast, Heimberg and Becker (2002) argue that cognitive restructuring techniques are most beneficial later in the treatment process. The rational for the alternate timing is that challenging the core schema cognitions too early in the process may not allow for a readiness to examine these thoughts and instead it may be more optimal to use alternative strategies earlier on. In addition, the advised appropriate timing of the Socratic method has been slightly different according to different researchers. Some scholars argue that using Socratic questioning is most affective within the exploration and assessment phase of therapy (Dattilio, 2000). Beck and colleagues (1993) also described how the Socratic method is more optimal in the earlier stages of treatment. However, DiGiuseppe (1991) reasoned that applying the Socratic elenchus should be incorporated into the therapeutic process after the patient has made some progress. Finally, additional researchers have advised that the timing of when the Socratic method is used is less important. Kennerley (2007) reported that this technique could be beneficial to the therapeutic process throughout the entirety of treatment. There appears to be a lack of cohesion in the suggestions regarding optimal timing of therapist techniques within CBT. These inconsistencies may have important implications for treatment and perhaps may affect the systematic application of CBT across clinicians.

The delivery of cognitive restructuring techniques has received some criticism from other theoretical perspectives. Theoretical approaches such as Dialectical Behaviour Therapy (DBT) and client-centered approaches draw awareness to limitations in the application of cognitive techniques in CBT. Leahy and Rego (2012) argue that other approaches such as DBT suggest that restructuring cognitions tends to make patients feel invalidated. They describe how DBT CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 26 theory instead encourages the patient to balance acceptance-oriented validation strategies with more change-oriented strategies. Moreover, theorists have also raised some concern over the leading quality of some cognitive restructuring techniques (Carey & Mullan, 2004). For instance,

Socratic questioning is argued to have a high level of directedness, which may lead the patient to a certain outcome rather than have them determine a particular outcome. These critiques of cognitive restructuring in CBT from other approaches (e.g., specifically DBT) are arguably important to consider when evaluating these techniques and applying these techniques in clinical settings.

Although many studies have demonstrated the effectiveness of cognitive restructuring techniques, many studies have provided conflicting evidence. One criticism has been regarding the effectiveness of these techniques compared to other therapeutic strategies within cognitive behavioural treatment. Some researchers have examined the importance of cognitive restructuring and have not found a significant effect on treatment outcome when adding these cognitive techniques to existing treatment. For instance, Foa and colleagues (2005) provided patients with Post-Traumatic Stress Disorder (PTSD) and symptoms of depression with either prolonged exposure alone or prolonged exposure with the addition of cognitive restructuring.

They found that both treatment groups decreased PTSD and depression symptomology; however, cognitive restructuring did not improve patient outcome compared to prolonged exposure alone.

Additional studies have suggested that cognitive techniques within CBT may not be as effective at reducing depressive symptoms as behavioural components. Dimidjian and colleagues

(2006) compared patients with Major Depression across different treatment groups. The researchers dismantled the components of CBT into behavioural and cognitive components and compared these treatment groups to antidepressant medication. Results demonstrated that CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 27 behavioural activation and medication were equally efficacious treatments and both treatments outperformed the group that focused more on cognitive techniques and interventions. There have been additional component analyses that have examined the components of CBT and have demonstrated no significant differences among techniques and strategies. For example, Jacobson and colleagues (1996, 2000) provided evidence that the outcome of a full application of CBT did not significantly differ from the application of specific components. Research on component analyses that have not demonstrated differences appear to raise some questions regarding the use of cognitive restructuring techniques. However, there are studies that also demonstrate the contrary. For instance, Taylor and Marshall (1977) demonstrated that administering full CBT was more effective with regards to reducing depressive symptomology compared to the application of only behavioural components or cognitive components. Further research is needed in order to better understand the effect and importance of cognitive restructuring techniques compared to other related techniques within CBT.

Behavioural Activation Techniques

Definition and examples of techniques. Behavioural Activation consists of working with the patient to schedule activities in their daily life that will be positively reinforcing (Kanter

& Puspitasari, 2012). Reinforcement increases the likelihood of a behavior occurring. Positive reinforcement is one of the central focuses of behavioural activation strategies and is specifically incorporated, as is integral to the theoretical underpinnings of behavioural treatments (Manos et al., 2010). Although behaviour activation techniques aim to increase a patient’s contact with positive reinforcement they are also used to target negative reinforcement. The sources of reinforcement are carefully considered and are selected based on their personal value to the patient, the stability of the reinforcement, and ensuring there is some diversity in reinforcements. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 28

Additionally, the reinforcements are collaboratively developed between the therapist and patient.

There are a number of behaviour activation interventions; a review was conducted by Kanter and colleagues (2010) identified techniques such as activity monitoring, assessment of goals and values, activity scheduling, skills training, relaxation training, contingency management, procedures for targeting verbal behaviour, and procedures for targeting avoidance.

Effects on patient outcome. There have been numerous studies that have explored behavioural activation (BA) techniques in relation to outcome and compared BA with other techniques and treatment. Hopko, Lejuez, Lepage, Hopko, and McNeil (2003) explored the treatment of psychiatric inpatients diagnosed with depression and assigned them to the behavioural activation condition or the standard supportive treatment condition. The behaviour activation condition consisted of therapist techniques such as activity monitoring and activity scheduling. The participants within the BA condition were found to have significantly lower levels of depression at post-treatment compared to the standard care condition. Although the treatment was very brief the study demonstrated significantly better outcomes for those who were assigned to the behavioural activation treatment group.

Behavioural activation techniques have also been systematically compared to cognitive restructuring techniques. Shaw (1977) conducted a study to compare a non-directive control group, a treatment group focusing on cognitive modification, and another treatment group focusing on behaviour modification. Within the cognitive treatment group, the therapists utilized a number of strategies and techniques that included recording thoughts, identifying cognitive distortions, and empirically testing attitudes, beliefs and assumptions. The behaviour modification group applied techniques in line with Lewisohn’s (1974) approach to behavioural therapy, which incorporated activity scheduling, verbal contracts, and behavioural rehearsal CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 29 techniques such as social skills training. Shaw found that the cognitive modification group had the most effective outcomes in reducing symptoms of depression when compared to other groups. This study suggests that treatments focused on cognitive restructuring techniques were associated with patients experiencing greater alleviation of depression symptoms.

Maldonado Lopez (1982) conducted a similar study that also evaluated therapist technique in patients diagnosed with depression. The therapeutic techniques that were compared included cognitive restructuring and behavioural assertiveness training, which were further compared to pharmacological control. The results revealed that both behavioural and cognitive techniques were superior to pharmacology in reducing symptoms of depression. However, the cognitive restructuring group was related to the lower rates of relapse when compared with behavioural techniques. These studies appeared to demonstrate some improved outcomes for patients who experienced cognitive restructuring techniques during treatment in terms of reduced depression and lower rates of relapse. Many studies compare groups of behavioural activation strategies and cognitive restructuring strategies, and a review of the existing randomized control trials is needed in order to start to draw conclusions.

Behavioural activation techniques have been further compared with cognitive techniques and with the full CBT approach. Taylor and Marshall (1977) examined cognitive behavioural therapy by comparing three treatment groups to a control group. Participants who were diagnosed with mild to moderate depression were allocated to behavioural therapy, cognitive therapy or full CBT. Severity of depression symptomology was assessed at pre and post- treatment. Taylor and Marshall found that each treatment group was more effective than waitlist controls. When comparing the behavioural therapy and cognitive therapy group, both groups demonstrated no difference in patient outcome. When the behaviour treatment alone and the CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 30 cognitive treatment alone were compared to the combined approach of CBT, results demonstrated an important difference. CBT was found to be more effective than either component alone. The results suggest that the combination of cognitive and behavioural components may be associated with greater reductions in depressive symptoms.

Recently there have also been meta-analyses conducted that have demonstrated the effectiveness of behavioural activation techniques across empirical studies (Cuijpers et al., 2007;

Ekers et al., 2008; Mazzucchelli et al., 2009). Cuijpers and colleagues (2007) completed a meta- analysis and identified 16 studies that in total included 780 patients. The study specifically identified the technique of activity scheduling as behavioural activation and compared this intervention to other psychological or pharmacological treatments. The participants included within the study were all being treated for depression and included both adults and older adults.

The meta-analysis demonstrated that behavioural activation was an effective treatment but when compared with various psychological approaches it was not found to be significantly more effective. When behavioural activation was specifically compared with cognitive therapy the results demonstrated that there was a non-significant difference across treatment conditions.

Ekers and colleagues (2008) conducted a meta-analysis investigating behavioural activation but used slightly different parameters. The researchers included treatment studies that focused on patients diagnosed with depression and symptoms were measured at pre and post treatment. The study included 17 randomized control trials, for a total of 1109 participants. They compared BA treatment with CBT, brief psychotherapy, supportive counseling, and treatment as usual/control. The results demonstrated that the treatment that focused on behavioural activation techniques was significantly more effective than supportive therapy, brief psychotherapy, and controls. When BA was compared to CBT, both treatments were found to be equally effective. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 31

Ekers and colleagues’ results suggested that behavioural activation treatments were effective for treating major depression similar to CBT even without the incorporation of cognitive restructuring techniques.

Mazzucchelli and colleagues (2009) conducted a meta-analysis also focusing on comparing psychological treatments with behavioural activation. Within their analysis they included 34 studies that included 2,055 participants. The participants were either diagnosed with depression or had elevated symptoms of depression. They identified BA treatment as strategies or techniques that encourage the participant to interact or engage with the environment in a way that reduces punishment and increases more positive reinforcement. Within their description of

BA treatment, the interventions included four variants of the approach, which were identified as pleasant activities, self-control, contextual (e.g., defined as including the interventions of activity scheduling, self-monitoring, graded-task assignment, and role-playing), or behavioural activation. The comparison groups included control conditions, CBT, or other treatment, which consisted of interpersonal therapy, brief psychodynamic therapy, supportive counseling, problem solving, assertiveness training, or psychoeducation. Results indicated that BA was effective for treating depression and their analysis found BA alone to be as equally effective as full CBT.

When examining differences among the variants of BA they found that contextual BA as described by Jacobson and colleagues (1996, 2000) demonstrated slightly improved effects; however, results were not statistically significant. The study further reported on depression levels at a 24-month follow-up and these results demonstrated that BA had equal effects to CBT at this time point. The meta-analyses provided evidence for BA techniques alone to be equally effective to full CBT treatment. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 32

Criticisms and limitations of current research. Empirical evidence generally supports the use of behavioural activation techniques, although there is clearly some need for reconciliations surrounding the operationalization of the various constructs. Hopko, Lejuez,

Ruggerio, and Eifert (2003) have noted that behavioural activation concepts described in treatment protocols and in research studies differ in how they are defined. There is some lack of consistency in the descriptions of terms, which potentially has implications for the generalizability of research studies and the reliable delivery of techniques. Further, differentiating among the techniques compared to applying more umbrella terms that capture related but slight differences seem to be common in the literature. For instance, various BA techniques have been categorized under activity scheduling rather than drawn out as individual techniques (e.g., Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al., 2009). It appears some researchers will ascribe to identifying specific techniques while others refer to the techniques as BA treatments. Achieving greater consistency in the literature and among treatment manuals may assist in providing a clearer understanding for practitioners and for researchers attempting to study and apply the techniques.

There have been some criticisms in the composition and delivery of behavioural activation techniques. Interventions that incorporate BA as a component of CBT or that center on

BA treatment differ widely in what techniques the treatment is composed of. Kanter and colleagues (2010) explained that the techniques that are administered within a trial often substantially differ. In addition, the delivery of these techniques or when they are suggested to be implemented in the treatment process can vary. Kanter and colleagues (2010) make some suggestions regarding when each technique should be applied in the treatment process but the ideal timing, most effective ordering of, and the optimal combination of the techniques could CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 33 benefit from more clear guidelines. Behavioural activation techniques have received substantial support but producing further studies to understand and maximize the effect of therapists, specifically in relation to patient outcome could have important empirical and clinical implications.

Activity scheduling has been coined as the cornerstone within behavioural activation techniques (Kanter et al., 2012). This technique has been demonstrated to be effective with patients struggling with Major Depression (Cuijpers et al., 2007). Scholars have argued that activity scheduling in the absence of other behavioural activation or cognitive restructuring techniques is possibly as effective as more complex combinations of the techniques (Ekers et al.,

2008). Additionally, researchers have suggested future studies may investigate the nuances or slight variations of activity scheduling that seem to fall within this technique (Kanter &

Puspitasari, 2012). For instance, examining strategies such as graded task assignments or structured hierarchies. It appears that furthering research related to specific behavioural activation techniques could have important clinical implications. The first step appears to be to delineate the techniques that are included within treatment conditions that include behaviour activation strategies.

Therapist Technique in Cognitive Behaviour Therapy: A Need for Future Research

There has been a substantial amount of research on therapist technique in CBT and many studies have focused on patients with Major Depression. There are numerous techniques that have been identified and described with cognitive restructuring and behavioural activation techniques. These techniques have been delineated within empirical studies and treatment manuals, and although there are commonalities, there are also some inconsistencies in how techniques are defined and differentiated. Future studies may consider ultimately working CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 34 towards a more universal and commonly accepted understanding and conceptualization of the specific techniques that are included within manualized CBT. Kanter and colleagues (2010) began to develop a more systematic list of behavioural activation techniques following a systematic review. Although treatment manuals often list and outline techniques it does not appear that there has been a current systematic review that specifically and clearly outlines cognitive restructuring and behavioural activation techniques. Further research into understanding therapist technique in CBT may assist in streamlining techniques and increase consistency across studies and within clinical practice. The present dissertation will begin to review and describe cognitive restructuring interventions.

Through reviewing the literature on therapist technique and CBT it appears there is an abundance of quantitative analyses and these studies have significantly contributed to our understanding of this research area. There are far fewer studies that have examined aspects such as therapist technique qualitatively; Day, Thorn and Kapoor (2011) have indeed noted that few studies have examined CBT through qualitative approaches and they described how the research literature would benefit from having future studies incorporate qualitative analyses.

Implementing qualitative methods within the research design can enhance current understandings and augment knowledge that has been developed through quantitative methods. Day and colleagues specifically indicated that the application of qualitative analyses allows researchers to uncover components of treatment that are inaccessible through more quantitative approaches. For example, uncovering recommendations commonly suggested across treatment studies and treatment could be one approach to further understanding and then testing therapist technique in

CBT. Berg, Raminani, Greer, Harwood, and Safren (2008) suggested that information gleaned from qualitative studies could inform the refinement of treatment components and identify CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 35 patient needs that could enrich our understanding of CBT. For instance, Kanter and colleagues

(2010) completed a review of behavioural activation strategies and provided a comprehensive list of therapeutic strategies. This review allowed for a more in depth understanding of techniques, how they were defined and they uncovered implications for clinical practice. Kanter and colleagues (2010) described nuances within each strategy (e.g., administering interventions in specific phases of the treatment) that they were able to extract and summarize from analyzing the studies from a more qualitative approach. Future research approaching therapist technique in

CBT could benefit from the inclusion of qualitative methods in order to promote a richer and more comprehensive understanding of therapist technique in CBT. This dissertation will incorporate qualitative analyses in order to identify and summarize current knowledge of recommendations for applying therapist techniques.

Another criticism is the minimal attention towards modifying therapist technique to individual differences between clients. For instance, Norcross and Wampold (2011) suggest that it is important to adapt technique to patient characteristics. Some recommendations they suggested were to adapt technique based on culture, resistance to psychotherapy, stages of change, coping style and attachment style. Norcross and Wampold reported considering the client’s unique needs and that tailoring therapist technique can improve treatment outcome. CBT techniques are often administered in a more fixed manner rather than adapting technique to important patient characteristics, such as culture. There has been limited research on adapting

CBT to be sensitive to different cultures but preliminary research appears to show some support for adapting CBT based on this important patient characteristic (Naeem, Waheed, Gobbi, Ayub,

& Kingdon, 2011; Rossello, Bernal & Rivera-Medina, 2008; Wong, 2008). For example, Naeem and colleagues (2011) demonstrated that adapting therapist technique to be more culturally CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 36 sensitive was related to more effective outcomes when working with patients identifying as

Pakistan who struggle with depression and anxiety.

An additional consideration in terms of individual differences among patients is their level of functioning. For instance, scholars have argued that traditional CBT approaches are potentially less effective for patients struggling with treatment resistant depression. McPherson,

Cairns, Carlyle, Shapiro, Richardson, and Taylor (2005) reviewed randomized clinical trials that specifically investigated CBT with patients with treatment resistant depression and found inconclusive evidence for the use of this approach with more severe forms of depression.

Scholars have noted that there is a need for adaption of techniques based on depression severity and have made suggestions on ways to alter therapist technique. For example, Eisendrath,

Chartier, and McLane (2011) recommended incorporating more mindfulness strategies, and

Watkins and colleagues (2007) suggested focusing more on techniques targeting rumination. The latter additionally suggested enhancing focus on behavioural activation strategies with patients who are struggling with more resistant forms of depression. Many scholars have acknowledged the importance of considering unique and important patient differences when applying therapist technique and there appears to be a further need to examine adaptions and better understand optimal ways to deliver CBT interventions.

Through reviewing outcome studies related to technique there have been some important findings that shed light on the importance of different techniques and some quite significant inconsistencies that need to be taken into consideration and point to a need for further research.

When reviewing studies pertaining to cognitive restructuring techniques, there seems to be many techniques that relate to reductions in depression symptomology (Braun et al., 2015; DeRubeis et al., 1990). However, some studies (Jacobson et al., 2000) indicate cognitive restructuring CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 37 strategies may not be a central set of strategies in the treatment of depression from a CBT treatment approach. Additionally, this appears to be the case when considering BA techniques.

For instance, Ekers and colleagues (2008) suggest the importance of BA such as activity monitoring yet when individual BA strategies are compared to cognitive restructuring, results have indicated differently (Shaw, 1977), Although there are inconsistencies, empirical studies generally tend to demonstrate that both cognitively and behaviourally focused techniques promote improved outcomes in depressed patients. Several studies demonstrated that BA techniques or cognitive restructuring techniques may generally be more effective than other treatment approaches that included interpersonal therapy, and brief psychodynamic therapy

(Mazzucchelli et al., 2009). The individual studies that were reviewed that specifically compared

BA techniques with cognitive restructuring techniques showed some but not an overwhelming amount of support for cognitive restructuring techniques over BA techniques. Further, one study revealed that full CBT which included both cognitive restructuring and BA was more effective than either alone (Taylor & Marshall, 1977). However, when examining various meta-analyses, each study seemed to draw towards the conclusion that BA was equally effective to Cognitive

Therapy (CT) and combined CBT (Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al.,

2009). If one were to give greater weighting to the meta-analytic studies it would appear that BA techniques alone are equally effective and efficacious to full CBT. This may call into question the importance of cognitive restructuring components as the addition of these techniques did not according to the meta-analyses relate to improved outcomes (Cuijpers et al., 2007; Ekers et al.,

2008; Mazzucchelli et al., 2009).

CBT is one of the most widely accepted treatments and compared to behavioural approaches alone it is associated with some practical disadvantages that may warrant the CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 38 consideration of comparable alternatives. For instance, BA has been suggested to be more cost- effective and more efficient compared to full CBT (Jacobson & Gortner, 2000; Robinson,

Wischman, & DelVento, 1996). BA tends to require fewer treatment sessions, which is associated with lower treatment costs (Cullen, Spates, Pagoto, & Doran, 2006). In recent years the National Institute of Mental Health (NIMH, 2005) has highlighted the need for more cost- effective treatment alternatives and has specifically suggested behavioural interventions as one of the areas for further research attention. An additional practical concern that warrants consideration is the differential training implications when learning full CBT techniques compared to behavioural techniques. Martell and colleagues (2001) argue that BA interventions are less complicated to train clinicians in and that they can more easily master the application of behavioural techniques compared to more intricate cognitive strategies. Indeed, therapists with different training backgrounds seem to learn these techniques more easily (Chambless & Hollon,

1998). Further, patients may be more able to learn and absorb behavioural approaches.

Chambless and Hollon (1998) suggest BA may be more easily implemented with patients at different levels of cognitive ability and varying skill level. There is clearly a need for more research examining behavioural and cognitive techniques, given the important economic and training implications.

Conclusion

The purpose of this narrative review was to explore the current knowledge on therapist technique in CBT. More specifically, cognitive restructuring and behavioural activation techniques were identified and described, and research related to patient outcome was examined.

There were a variety of techniques that were delineated and the application of each technique was discussed. Through reviewing the literature many criticisms and limitations were outlined CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 39 for each technique. With regards to cognitive restructuring there appeared to be a lack of research on specific techniques and how they related to depression reduction, there were some inconsistencies surrounding optimal timing of the application of techniques, and criticisms from other treatment approaches specific to cognitive restructuring techniques were highlighted.

Further, after reviewing outcome studies there appeared to be some contradictory evidence regarding the effectiveness of the cognitive restructuring techniques especially compared to other

CBT techniques in the reduction of Major Depression. When evaluating the empirical literature on behavioural activation techniques there appeared to be variability in how techniques were operationalized, questions surrounding optimal combinations of techniques and only approximate ideas regarding the ordering of techniques.

The final purpose of this review was to develop suggestions for future research studies on therapist technique in CBT through exploring and detecting the gaps in the research literature.

Through this review it was apparent that therapist technique in CBT would benefit from further investigations. Several ideas were generated that included a need for greater consistency across definitions for specific therapist techniques and a potential need for a systematic review specifically for cognitive restructuring techniques. Additional suggestions included a clearer understanding of how cognitive restructuring and behavioural activation techniques compare and relate to improved outcomes for patients diagnosed with depression. These studies would be particularly important as they could justify the somewhat costly training of cognitive techniques or potentially suggest increases in treatments focused on more behavioural activation techniques.

Further, suggestions were made on additional methods that could be used when examining therapist technique in CBT. This included employing qualitative approaches to obtain CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 40 a more in depth understanding of therapist technique in CBT. Qualitative methods could augment quantitative research by offering an alternative perspective and help to continue to refine our understanding how CBT techniques are being applied. Furthermore, there appeared to be a need to consider and investigate individual patient differences when delivering therapist technique in CBT, such as level of patient functioning. In all the area of therapist technique in

CBT for Major Depression was found to be an important future area of examination that could have various research, training and clinical implications.

This Dissertation

This thesis will involve three manuscripts related to therapist technique within Cognitive

Behavioural Therapy. The overarching purpose of this research endeavor is to better understand therapist technique in CBT through exploring and examining existing research. To do this, three interrelated studies have been designed. Manuscript one and two will explore cognitive restructuring techniques through a scoping review. Given the extensive literature on cognitive techniques, manuscript one will focus on cognitive techniques targeting automatic thoughts and manuscript two will focus on cognitive techniques targeting core beliefs. Each manuscript will contain a review to identify and define individual cognitive techniques, and uncover clinical recommendations pertaining to how to best delivery cognitive interventions. The third manuscript will focus on behavioural and cognitive interventions in relation to treatment outcome. More specifically, a systematic review will be conducted to examine efficacy of cognitive interventions, and behaviour activation interventions compared to comparators in the effect on reduction of depression symptomology.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 41

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Brief Overview

Chapter one provided an introduction to therapist techniques in CBT and identified core constructs such as cognitive interventions and behaviour activation interventions. The literature review indicated a need for further research and specific areas for future research. The following chapters will be composed of the three manuscripts, which aim to address these identified research gaps.

Chapter two and chapter three will focus on a large scoping review that explored cognitive interventions. Given the long history of CBT and the abundance of data available

(Beck, 1967), the review is presented in two manuscripts. The overarching aim of the scoping review was to identify and define cognitive interventions, and to describe clinical recommendations suggested for delivering cognitive interventions. Chapter two will focus on techniques that target automatic thoughts and their respective clinical recommendations. Chapter three will focus on a separate category of cognitive interventions that target core beliefs and clinical recommendations that pertain to interventions for core beliefs. Future research ideas will be discussed and clinical implications will be highlighted.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 53

Chapter 2 - Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of

Cognitive Interventions Targeting Automatic Thoughts in Major Depression

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 54

Running head: THERAPIST TECHNIQUES FOR AUTOMATIC THOUGHTS

Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of Cognitive

Interventions Targeting Automatic Thoughts in Major Depression

Amanda R. Sheptycki, Emma Schmelefske, Emily Kingsland, Michelle Azzi, & Martin Drapeau

McGill University

Address Correspondence to Dr. Martin Drapeau, SAPP Lab-McGill, 3700 McTavish,

Montreal, Quebec, H3A 1Y2; email: [email protected]

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 55

Abstract

Cognitive Behavioural Therapy (CBT) for major depression is composed of techniques that target thoughts and behaviours. Cognitive techniques are believed to target central cognitive constructs such as automatic thoughts. Given the vast amount of literature describing different cognitive techniques used for the treatment of major depression, there has been an increasing need for a scoping review that consolidates and summarizes techniques specifically directed at automatic thoughts. While techniques related to the behavioral activation within CBT have been reviewed and summarized, there is a gap in the literature related to reviewing cognitive techniques that target automatic thoughts. The present review aimed to specifically focus on describing interventions and clinical recommendations for this central cognitive construct in the treatment of major depression. The scoping reviewing consisted of a literature search using

PsychINFO, EMBASE and Medline. The methodology followed the framework developed by

Arksey and O’Malley (2005) and thematic analysis guidelines established by Braun and Clarke

(2006). The review uncovered specific cognitive techniques for identifying, exploring and modifying automatic thoughts and offered clinical recommendations for each set of techniques.

Keywords: Cognitive interventions, therapist techniques, automatic thoughts, major depression

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 56

Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of Cognitive

Interventions Targeting Automatic Thoughts in Major Depression

Cognitive Behavioural Therapy (CBT) has been established as an evidence-based treatment for major depression (Lam et al., 2016). A landmark component analysis conducted by

Jacobson and colleagues (1996, 2000) was the first to separate CBT into its core components for comparison. This study included a randomized control trial with individuals meeting criteria for major depression, comparing three arms that allowed for direct comparisons of full CBT to treatment focused exclusively on behavioural activation and treatment focused on automatic thoughts. Results demonstrated that the behavioural activation treatment, as well as the automatic thought treatment arms were as efficacious as full CBT. Other researchers have also compared cognitive and behavioural components of CBT. For example, Dimidjian and colleagues (2006) examined behavioural activation, cognitive therapy and antidepressant medication in patients who struggled with major depression. The researchers reported that behavioural activation and pharmacological treatments had comparable effects on symptom reduction. Further, both treatments were shown to be superior to cognitive therapy. Clore and

Gaynor (2012) have suggested that CBT can be further dismantled into even smaller components or techniques, and that treatment packages consisting of some of these techniques can be as effective as full CBT. In sum, by dismantling CBT into components and comparing their relative effectiveness, these studies highlighted the importance of studying techniques of CBT.

There are a several techniques within Cognitive Behavioural Therapy that are used for patients with major depression. Two broad and highly common clusters of techniques that are detailed within treatment manuals are behavioural activation techniques, and cognitive CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 57 techniques (Kanter & Puspitasari, 2012; Leahy & Rego, 2012; Young, Rygh, Weinberger, &

Beck, 2001). Behavioural activation techniques are used to activate the patient by having them engage in scheduled activities that are positively reinforcing (Manos, Kanter, & Busch, 2010). In order to develop a comprehensive list of behavioural activation techniques used within CBT,

Kanter and colleagues (2010) conducted a systematic review in order to develop a comprehensive list of behavioural activation techniques, and these included activity monitoring, assessment of life goals and values, activity scheduling, skills training, relaxation training, contingency management, procedures targeting verbal behaviour, and procedures targeting avoidance.The benefits of developing this list include providing a more systematic listing and overview of techniques for clinicians when administering treatment to patients and for researchers when studying behavioural activation techniques.

Cognitive restructuring or cognitive techniques are incorporated within CBT and are largely administered to target negative automatic thoughts. Automatic thoughts have been defined as unstable, temporary and situation-specific thoughts (Beck, 1967). Beck (1963, 1967) found that patients with major depression tend to exude a patterned way of negative thinking that he identified as the cognitive triad. The cognitive triad is observed when an individual has an overly negative way of thinking about him or herself, the world and the future. According to cognitive behavioural approaches, cognitive restructuring techniques are largely important as they utilize procedures that identify, challenge and modify maladaptive thinking into more adaptive and flexible ways of processing information. Some cognitive techniques include the

Socratic method, empirical hypothesis testing and logical analysis (Leahy & Rego, 2012).

There have been a number of manuscripts, book chapters and manuals that have delineated numerous cognitive techniques; however, a more comprehensive review of cognitive CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 58 interventions is not readily available. Exploring techniques identified across manuals and working towards a more cohesive list similar to Kanter and colleagues’ (2010) review on behavioural activation interventions, will assist in addressing this research gap. A scoping review will also have implications for practice. For instance, a review could provide a clear and systematic guide for practitioners and trainees in clinical settings. Clinical recommendations will be identified and are defined as recommendations for how interventions may be applied over treatment for patients with major depressive disorders (Kantor et al., 2010). In all, this review will address this gap in research and have an array of future clinical implications.

The present scoping review aimed to examine cognitive techniques commonly delivered in CBT that target automatic thoughts in the treatment of depression. Specifically, this scoping review aimed to examine existing clinical resources and empirical studies to (1) identify specific cognitive techniques used to target automatic thoughts, (2) define these techniques, and (3) provide clinical recommendations for the use of these techniques.

Method

The present review was part of a larger scoping review that reviewed cognitive interventions within CBT for major depression. Given the large scope of the full review, this paper focuses on describing cognitive interventions and clinical recommendations specifically targeting automatic thoughts in major depression.

The method used to conduct this study followed Arksey and O’Malley’s (2005) framework. The framework was composed of five steps including identifying the research question, identifying relevant studies, selection of studies, charting the data and collating, summarizing and reporting the results. The thematic analysis further followed Braun and

Clarke’s (2006) recommendations for scoping reviews. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 59

Following the first step of Arksey and O’Malley’s (2005) framework, the specific research questions related to the cognitive construct of automatic thoughts, specifically in the treatment of major depression for adults included: (1) What are the overarching core therapeutic techniques? (2) How are the therapeutic techniques defined? (3) What are core clinical recommendations for delivering these therapeutic techniques? In the second step, a search string was developed to identify the relevant studies. A librarian from McGill University was consulted to develop the search strategy. The search was executed in three electronic databases including

PsychINFO, Embase and Medline, between 1964 to 2018 (see Appendix A to C). In order to ensure additional records such as treatment manuals and book chapters were captured, a hand search was carried out in World Catalogue. Further, reference lists were reviewed from core records and incorporated. The review resulted in a large number of records (n = 5669) identified to be relevant for the study; a PRISMA flow diagram (Moher, Liberati, Tetzlaff, & Altman,

2009) was used to chart the results (see Figure 1).

The third step of selecting the studies was performed by two reviewers, and was supported by a third reviewer if disagreement occurred. Reviewers were doctoral students in counseling psychology with clinical training in CBT, and previous experience in scoping and systematic reviews. After duplicates were removed (n = 4517) records were first screened at the abstract level, resulting in a second level of review at the full-text level (n = 191). Detailed inclusion and exclusion criteria were applied at each level and included seven criterion consisting of population type, disorder or medical condition, intervention type, orientation, discipline, source and language. Within population, records were included if they focused on adult populations and excluded if they focused on children, adolescents (e.g., under 18 years of age) or older adults (e.g., 65 years of age or older). Given the nature of techniques included that CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 60 focus on cognition, we excluded age groups that are at different stages with regards to cognitive development (Blackburn & Papalia, 1992). For disorder or medical condition, the record was included if the focus of the intervention was targeting major depressive disorders. With interventions, the record needed to include information on therapist techniques that targeted cognition. Cognitive interventions were defined as a technique that targeted maladaptive or distressing thoughts or faulty information processing. Records were excluded if they focused on cognitive intervention that targeted neural functioning such as memory enhancement. Articles that did not discuss CBT or third wave approaches were excluded. For the source criterion, the study included peer-reviewed articles, various types of books including manuals, handbooks, facilitator’s guides, and theoretical books. Given the vast amount of records, the study excluded grey literature.

The fourth step of the framework was conducted by four reviewers who completed the data extraction on the selected included records (n = 105). The reviewers consisted of two trained doctoral students, one master’s student and an undergraduate student. Consultations occurred in order to ensure reliability across raters. The reviewers extracted relevant information such as publication type, patient diagnosis, treatment type, duration, number of sessions, demographics, and study design (see Appendix A in supplemental materials).

The fifth step included collating, summarizing and reporting the results of the selected records (n = 105). Within this stage the thematic analysis was conducted (Braun & Clarke,

2006). Two reviewers familiarized themselves with the records and met regularly to generate initial codes. Each record was coded and codes were extracted into an excel document. Codes were then reviewed and initial themes were developed. Reviewers agreed upon themes and themes were defined into three overarching groups: identifying, exploring, and modifying CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 61 techniques. Sub-themes (n = 24) or individual techniques were also identified and defined after consultations among reviewers. Additionally, within each of the three overarching groups there were clinical recommendations that were delineated (n = 11), consisting of three to four recommendations for each overarching category. Clinical recommendations were conceptualized as any statement that discussed how a cognitive intervention may be applied, for instance, when in the treatment process an intervention was suggested to be delivered. Finally, after the themes were clearly delineated and defined, the analyst summarized and reported the results. Inter-rater validation was conducted on approximately 30% of the records. Given the qualitative nature of the ratings and consistent with a similar study by Kanter and colleagues (2010), an Intra-Class

Coefficients (ICC) was not calculated. In order to manage inter-rater reliability, two raters completed independent ratings and held consensus meetings to compare ratings. If disagreements could not be resolved, a third rater was available. Additionally, a senior researcher with expertise in CBT was consulted to review the final themes.

Results

The scoping review identified three overarching groups of cognitive techniques that were applied to automatic thoughts: (1) identifying techniques, (2) exploring techniques, and (3) modifying techniques. In this review, each overarching group of techniques was described, individual core techniques within the groups were defined, and clinical recommendations pertaining to each overarching group were discussed.

Identifying Techniques

Definition. Identifying automatic thoughts was noted as a core treatment strategy in

CBT, which has a number of related and more specific interventions (Covi, Roth, & Lipman,

1982; Dowd, 2004; Freeman, 2006; Goddard, 1982; Hallis et al., 2016; Hollon & Garber, 1990; CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 62

Longmore & Worrell, 2007; Peterson, Sprich, & Wilhelm, 2016; Schuyler, 2003; Young et al.,

2014). By identifying automatic thoughts, patients learn to self-monitor and to increase their awareness of negative thoughts relating to their depressive symptomology (Beck, 1976; Beck &

Beck, 2011a; Roberts & Hartlage, 1996; Sacco & Beck, 1995). This process not only highlights automatic thoughts in general, but also highlights those that are considered to be emotionally loaded or “hot thoughts” (Dunn, 1979; Moretti et al., 1990; Sudak, 2012). Holland (2016) defined hot thoughts as dysfunctional thoughts that elicit an intense emotion and these are indicated as the primary target for identification (Freeman & Oster, 1998; Overholser, 1995;

Yovel et al., 2014). Another type of automatic thought identified was self-directed critical thoughts, as suggested by Lam and Cheng (2001). Given the tendency for patients to distort perceptions of the self, world and others, these critical thoughts in particular are important to identify in order to challenge depressive cognitions. In sum, various types of identification interventions allow patients to recognize the automatic nature of thoughts and interrupt them

(Freeman & Oster, 1999; Moore & Garland, 2003a). These techniques include: identifying and labeling cognitive errors, eliciting automatic thoughts, observing and recording automatic thoughts, distancing and decentering, thought records, identifying themes, thought counting, and scaling.

Identifying and Labeling Cognitive Errors. One type of identification intervention was the identification and labeling of cognitive errors. A cognitive error is defined as a type of dysfunctional thinking that can be grouped into a patterned way of thinking, such as fortune telling (Beck et al., 1979; Freeman & Davis, 1990; Hallis et al., 2016; Howland, 1996; Rush,

1983; Thase, 2013). Cognitive errors were also referred to as cognitive distortions, thinking traps, or thinking errors, terms which are often used interchangeably (Fisher & Sprich, 2016). CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 63

This strategy consisted of psycho-educating patients on cognitive error types by providing them with a list of cognitive errors and their respective definitions (Sudak. 2012; Wright, Basco, &

Thase, 2006a). Patients are also guided to identify their own common cognitive errors (Bieling,

McCabe, & Antony, 2006; Freeman & Davis, 1990) and are encouraged to recognize and label the type as they arise (Covi et al. 1982, Freeman & Oster, 1999; Huppert, 2009). While applying interventions directed at cognitive distortions, the therapist may have the patient record the frequency, content and patterns noticed. The aim of this therapeutic technique is for patients to recognize that depression can alter or distort thoughts and for them to have a clinical tool that helps them identify these distorted patterns in thinking (Freeman & Davis, 1990; Sudak; Thase,

1997).

Eliciting Automatic Thoughts. Another type of identifying techniques are those applied to elicit automatic thoughts (Beck, 1979a). One of the most common means to elicit distressing or depressive cognitions is to have the patient recall a recent distressing event (Bieling et al.,

2006; Huppert, 2009; Thase, 1993; 1995). This strategy involves identifying an event that was associated with a strong emotional reaction and having the patient describe the event in detail

(Persons, Davidson, & Tompkins, 2001a). Young and colleagues (2014) and Roberts and

Hartlage (1996) suggested event recall involved the patients imagining or picturing themselves in the past situation. The use of imagery can be the impetus to identify the target thought or hot cognition (Yovel et al., 2014). The therapist may encourage the outlining of the chain of events that occurred prior to the increased affect (Sacco & Beck, 1995). In order to promote the elicitation of negative thoughts, the patient can also engage in role-play enacting a difficult situation or interpersonal interaction (Klosko, 1999a; Wright et al., 2006a; Young et al., 2014). CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 64

Additional ways to elicit automatic thoughts is through the use of questioning, such as inquiring about the meaning or personal significance of events (Beck & Beck, 2011a;

McCullough, 1984; Thase, 1995; Wenzel, 2017) and reflecting on verbal and non-verbal cues

(Beck & Beck, 2011a). By attending to and reflecting on these cues, therapists can help patients slow the process down and increase awareness of affect (Bieling et al., 2006; Peterson et al.,

2016). More specifically, the use of in-vivo shifts in mood can be a central way to elicit a hot thought by inquiring about what is passing through the mind in that given moment (Peterson et al., 2016; Thase, 1993). Taken together, these techniques and strategies help arouse or elicit negative automatic thoughts.

Observing and Recording Automatic Thoughts. Observing and recording of automatic thoughts is another common practice of identifying automatic thoughts (Beck, Rush, Shaw, &

Emery, 1979; Williams, 2004). Observation involves carefully self-monitoring the content of one’s mind and noting specific automatic thoughts (Beck, 1979b; Covi et al., 1982; Jarrett &

Nelson, 1987; Klosko & Sanderson, 1999; Roberts & Hartlage, 1996; Sanderson, & McGinn,

2001; Thase, 2013; Williams, 1989; 2004). The therapist guides the patient to increase their awareness of thoughts, feelings, distressing situations and physical sensations (Beck, 1979b;

Covi et al., 1982; Dunn, 1979; Knapp & Beck, 2008; Roberts & Hartlage, 1996; Rush, 1983;

Thase, 2013). In increasing awareness, the patient can be more attuned to thought content and images (Beck, 1979b).

Observing and recording dysfunctional cognitions offers many functions and is helpful for more advanced strategies introduced later in treatment (Piasecki & Hollon, 1987). The self- monitoring and recording can assist the patient in distancing and taking on a more objective perspective (Overholser, 1995b; Huppert, 2009). Systematic recording can highlight the active CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 65 role the patient has in perceiving their world and can offset the automatic nature of information processing (Hollon & Garber, 1990; O’Donahue & Fisher, 2008). The careful attention given to the awareness of cognitions can reduce avoidance and expose the patient to previously feared thoughts and emotions (Huppert, 2009), while also highlighting and disconnecting the tightly linked thought and emotion (Williams, 2004). Further, these techniques provide the groundwork for more advanced interventions. For instance, these identified thoughts are often subjected to testing, examination and modification (Piasecki & Hollon, 1987).

Distancing and Decentering. Distancing and decentering are another subset of identifying techniques that are often paired together (Beck, 1979b; Evans, 1988; Freeman &

Davis, 1990; Freeman & Oster, 1998; Jarrett & Nelson, 1987; Zettle & Hayes, 1987). Wenzel

(2017) described this technique as encouraging the patient to distance themselves from their thought processes. The distancing process allows for the patient to gain perspective and decenter from thoughts (Beck, 1979b; Freeman & Davis, 1990; Overholser, 1995b). This strategy aimed to facilitate the process of beginning to view thoughts as hypothetical rather than indisputable facts (Beck, 1979b; Jarrett & Nelson, 1987; Roberts & Hartlage, 1996). Distancing and decentering can be applied to past events and can provide a gap between current events to assist in being able to appraise events more systematically (Overholser, 1995b; Roberts & Hartlage,

1996). Through distancing from a thought, the therapist also assists the patient in gaining distance from the associated emotion (Beck, 1979b; Jarrett & Nelson, 1987). This intervention is thought to then lessen the emotional intensity and provide the decentering needed in order to prepare the patient to challenge cognitions (Roberts & Hartlage, 1996). Longmore & Worrell

(2007) suggested that this technique can be combined with other techniques such as reattribution CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 66 and alternative conceptualizations (these techniques are further detailed below in the

Challenging and Modifying techniques section).

Thought Records. Thought records are one of the most central and frequently applied techniques for identifying and modifying dysfunctional thoughts (Freeman, 2006; Greenberger &

Padesky, 1995; Perris, 1989; Persons et al., 2001a, Roberts & Hartlage, 1996; Wenzel, 2017).

This technique involved various elements of cognitive restructuring including identifying, examining, challenging, modifying and exploring alternative automatic thoughts (Clore &

Gaynor, 2006; Huppert, 2009; Thase, 1996). The thought record acted to initially teach the patient about the CBT model (Persons et al., 2001a), understand the relationship between thoughts and affect (Sudak, 2012; Thase, 1995), access and create awareness of thought processes (Kellogg & Young, 2008), and operationalize the meaning of a particular thought

(Fefergrad & Richter, 2013). The thought record is also applied as a major vehicle of change

(Persons et al., 2001a). The therapist has to work with the patient through an increasingly complex thought record whereby cognitions are analyzed and challenged, and alternative thoughts or more rational responses are developed (Knapp & Beck, 2008; Wright et al., 2011).

Additional Identification Techniques: Identifying Themes, Thought Counting and

Scaling. Once thoughts are identified they are often categorized into overarching themes (Beck et al., 1979; Overholser, 1995b). The therapist and patient work together to determine depressive themes or systematic biases in information processes that occur across multiple situations

(Goddard, 1982; Persons, et al., 2001a; Wright, Basco, & Thase, 2006b). The frequency of a thought is also identified through the strategy of thought counting (Covi, et al., 1982; Fennel,

1989; Rush, 1983). This strategy allows the patient to notice the repetitive and cyclical nature of maladaptive thoughts that are common among those struggling with major depression (Beck et CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 67 al., 1979). While this strategy is designed to promote awareness, it also functions to provide distance from automatic thoughts (Burns, 2012; Fennel, 1989). An additional identification strategy used to provide distance and objectivity is scaling (Freeman & Oster, 1999). Scaling is a technique that can be applied to identify the intensity of the emotional impact of a thought or degree to which one believes in a thought (Goddard, 1982; Yovel et al., 2014). This technique helps the patient to perceive their world as less of a dichotomy and more of a continuum

(Freeman & Davis, 1990). These techniques can all be applied to further identify and understand thought processes.

Clinical Recommendations.

Clinical Recommendation 1: Use identification strategies in the early phase of treatment. The process of teaching the patient to monitor and record automatic thoughts are considered a significant component of CBT (Beck, 1979b; Clore & Gaynor, 2006). Beck and

Beck (2011a) indicated that identifying thoughts is a therapeutic technique that can be applied as early as the first session. In early sessions, patients are urged to monitor their internal experiences including thoughts in the form of statements or images (Covi et al., 1982; Moore &

Garland, 2003a; Overholser, 1995; Zettle & Hayes, 1987).

Clinical Recommendation 2: Identify automatic thoughts in-vivo as they occur.

Scholars have noted important instances within session that are optimal for identifying negative thoughts. Beck (1979a) suggested highlighting the thought as it occurs within the session in real time. An additional recommendation for identifying thoughts is having the patient reflect on what was going through their mind during a shift in mood (Beck & Beck, 2011). When the patient encounters difficulty identifying the thought, Wright and colleagues (2006a) recommend applying an imagery exercise or drawing upon a prompt that has the patient reflect on a past CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 68 memory. Fennel (1989) suggested an extra prompt of encouraging the patient to reflect on the implicit meaning of a past distressing event.

Clinical Recommendation 3: Reinforce the patient when they identify an automatic thought. When identifying cognitive distortions, Freeman and Oster (1999) expressed the importance of reinforcing the patient for identifying the presence of a distortion, rather than ensuring the correct terminology or labeling of the distortion. Similarly, as the patient demonstrates shifts of small and large magnitude in depressive symptomology, reinforcing these changes and encouraging the patient to acknowledge or notice even more subtle shifts (Moore et al., 2003a).

Exploring Techniques

Definition. A second overarching group of cognitive techniques aimed at automatic thoughts are exploring techniques. These techniques are used to explore maladaptive thoughts and their degree of accuracy or validity (Freeman & Oster, 1999). This group of cognitive techniques is often used concurrently or before the use of challenging and modifying techniques

(see below). However, exploring techniques can be differentiated from the challenging and modifying techniques as they are often less directive and more explorative in nature compared to the latter. Exploring techniques include the inter-related strategies of guided discovery, logical analysis, hypothesis testing, Socratic questioning and questioning.

Guided Discovery. Bieling and colleagues (2006) described guided discovery as an intervention at the foundation of most cognitive therapeutic techniques. The key aspect of this strategy is that the therapist provides guidance through a process of discovery (Freeman & Oster,

1998; Freeman, 2006; Knapp & Beck, 2008). The exploration process is informed through considering case conceptualization and treatment goals of the patient (Freeman, 2005; Freeman CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 69

& Oster, 1998). Freeman (2006) explained that an important element of guided discovery is to unearth cognitive systems, especially core beliefs, that are less conscious and that have a large impact on more accessible thoughts and emotions. Applying this approach can enhance the patient’s ability to make connections between thoughts, behaviours and emotions, or between dimensions of cognitive structures such as thoughts, assumptions and schemata (Roberts &

Hartlage, 1996). Moreover, guided discovery acts as a strategy for noticing cognitive distortions

(Sanderson and McGinn, 2001), considering alternative ways of behaving, thinking and expressing emotion (Bieling et al. 2006), and providing a means to modify cognitive structures through integration with change-orientated strategies directed at automatic thoughts and core beliefs (Kellogg & Young, 2008). Thase (1993) also noted that the psychoeducational components of guided discovery emphasize central aspects of CBT such as the subjective nature of thoughts. Lastly, this intervention makes it easier for the therapist to overcome barriers such as avoidance and helps in remaining focused on difficult thought content or emotions (Freeman

& Oster, 1998).

Logical Analysis. Logical analysis is an additional intervention to explore automatic thoughts using a systematic and rational approach. Patients are taught to objectively review information through observing the therapist modeling this approach (Jarrett & Nelson, 1987;

Longmore & Worrell 2007). Logical analysis is often used in order to label distorted thought processes, identify the accuracy of the thought relative to reality, and differentiate between thoughts and facts (Jarrett & Nelson; Sudak, 2012). Logical analysis was closely related to and often paired with hypothesis testing (see technique described below) (Longmore & Worrell,

2007). CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 70

Hypothesis Testing. Hypothesis testing has also been referred to as examining hypotheses, generating hypotheses, hypothetical testing and self-hypothesis testing. It is similar to the aforementioned logical analysis technique as both techniques involve collaborative empiricism, whereby the therapist and patient work together in a scholarly investigation (Bieling et al., 2006; Freeman, 2006; Kellogg & Young, 2008). However, this intervention specifically requires teaching the patient to consider their thoughts as hypotheses that can be subjected to examination (Sacco and Beck, 1995; Williams, 2004). The therapist encourages the patient to set up and apply experiments to test thoughts and beliefs, thereby mitigating rigidity and increasing flexibly (Beck, 1979b). Cognitions are equated with interpretations and as one of many potential ways to view a situation, others or the self. The therapist and the patient can either collaborate to identify the hypothesis (Overholser, 1995) or the therapist can offer the patient potential hypotheses (Covi et al., 1982; Freeman & Davis, 1990; Segal, Williams, & Teasdale, 2002b). It is important that the hypothesis be stated in a form able to be tested and later reviewed

(Overholser, 1995). Once a hypothesis is examined and alternative hypotheses are developed, these alternatives can also be exposed to further examination (Covi et al., 1982).

Socratic Questioning. Socratic Questioning has been detailed and described by many researchers including Overholser (1988, 1993, 1995a, 1996a, 1999, 2011) and Beck (1979a,

1979b, 2005). This technique has been identified as the cornerstone technique (Clark & Egan,

2015) and the “Holy Grail of CBT” (Freeman, 2005). The Socratic Method involves an examination where the clinician and patient investigate cognitive structures through a collaborative process (Peterson, et al., 2016; Sudak, 2012). As the clinician is questioning the patient, the clinician must monitor the patient’s comprehension and understanding of the question at hand (Overholser, 1993). The key element of this method is the application of CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 71 systematic questioning (Beck & Beck, 2011a; Peterson et al., 2016) and a series of graded questions that guide the patient to identify and explore cognitive processes (Beck & Beck,

2011a; Bieling et al., 2006; Sudak, 2012). This method inhabits an open-ended questioning style or is framed in statements (O’Donahue, 2008). The Socratic Method can include the use of additional questioning styles described below. Lines of questioning are developed through the clinician’s case conceptualizations and the therapeutic treatment goals (Beck & Beck, 2011a).

Through this approach the clinician can assist the patient to think in a manner that is more flexible, systematic and rational (O’Donahue, 2008).

Questioning. Questioning is a key intervention that is often paired with various therapeutic techniques and incorporated throughout the treatment process (Young et al., 2014).

There are a number of different question types, each differing in function and complexity. They include: translation, interpretation, memory, application, synthesis, evaluation, and analysis

(Freeman, 2005; Lam & Cheng). Questioning is used to examine the patient’s thoughts and determine whether they are distorted and how they affect emotions (Lam & Cheng, 2001; Moore

& Garland, 2003a; Young et al., 2014). Through the use of questioning, the patient has the opportunity to identify and reflect on thoughts, schemas, ideas, and perspectives. This further allows the patient to suspend maladaptive thinking in order to explore and understand the idiosyncratic meaning behind the automatic thoughts (Dobson, 2008; Freeman & Davis, 1990;

Freeman & Oster, 1998; Young et al., 2014). Applying this technique prompts the patient to begin to recognize thoughts as subjective internal experiences as opposed to accepting thoughts as factual depictions of reality. This process allows for questioning and examining of cognitive structures, and enables the patient to expand or consider multiple perspectives (Baer & Walsh,

2016). While exploring and understanding a patient’s cognitions, it is important to elicit the CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 72 meaning behind the thought. The aim is to ensure cognitive content is clearly understood by the patient and the therapist, and the therapist can begin to comprehend potential distortions in how the patient perceives their reality (Freeman, 2006; Moretti et al., 1990).

Clinical Recommendations.

Clinical Recommendation 1: Introduce automatic thought exploration strategies in the first phase of treatment. The exploration of dysfunctional thinking techniques is considered to be an essential set of therapist techniques (Sacco & Beck, 1995). Specifically, it is recommended that the therapist and patient explore dysfunctional thoughts during the first phase of psychotherapy and prior to the use of interventions targeting core beliefs (Baer & Walsh, 2016;

Moore & Garland, 2003a; Persons et al., 2001a).

Clinical Recommendation 2: Spend a greater proportion of time exploring thoughts that are highly distressing and believable. A key component of thought exploration is assessing for the believability of the thought and degree of distress elicited by the thought (Peterson et al.,

2016). More specifically, when the believability and distress are highly elevated, the clinician is recommended to spend a higher proportion of time on eliciting the meaning of that thought.

Clinical recommendation 3: Mindfully disperse, vary, and adapt the use of questioning techniques. When using questioning techniques, it is suggested to deliver one question at a time

(Beck & Beck, 2011b; Overholser, 1993). Questions should be phrased in a way that is concise, specific and purposeful (Freeman, 2005). Therapists are invited to apply questioning strategies in moderation and to fluctuate between types of questioning such as Socratic and non-Socratic questioning styles (Engel & Morgan, 1973; Overholser, 1993). Alternatively, therapists can vary the type of questioning by incorporating different ways of phrasing such as through statements, reflections, or rephrasing (Overholser, 1995). Through the incorporation of multiple techniques CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 73 and allowing time in between questioning, the patient continues to actively think through the questions as opposed to feeling restricted in response time and giving responses that are more simplistic and less spontaneous (Long, Paradise, & Long, 1981). Finally, the therapist should be aware of the patient’s responses and adapt further questioning to the patient’s individual needs.

This requires the therapist to take in consideration aspects such as affect and case conceptualization (Overholser, 1995).

Challenging and Modifying Techniques

Definition. Challenging and modification strategies are a group of techniques aimed at restructuring and shifting cognitive sets (Freeman & Davis, 1990; Hallis et al., 2016; Wenzel,

2017). The goal is to assist patients in adjusting their thinking style to be more objective, realistic and helpful, as well as to help them manage and counter negative thought processes (Covi et al.,

1982; Dunn, 1979; Fennel, 1989; Freeman & Oster, 1999; Longmore & Worrell, 2007;

O’Donahue, 2008; Thase, 1993; Wright et al., 2006a). A range of modification strategies are applied to assist the patient in refuting maladaptive cognitions in a more functional, and rational way (Jacobson et al., 2000; Sacco & Beck, 1995; Young et al., 2014).

Evaluating Automatic Thoughts. A key therapeutic technique is evaluating or critically examining automatic thoughts (Freeman, 2006; Howl, 1996; Wenzel, 2017). Thoughts are evaluated to detect their validity and helpfulness (Beck, 2011; Longmore, 2007; Moretti, 1990).

For instance, the accuracy is considered and to what degree the thoughts are based on logical reasoning (Howland, 1996; Huppert, 2009; Jarrett & Nelson, 1987). Freeman and Davis (1990) specifically outlined automatic thoughts are systematically appraised for believability, impact on emotion and behaviour, and content. Additionally, the clinician helps the patient to assess the CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 74 impact on overall functioning and more specifically on affect and on maladaptive behaviours

(Overholser, 1995).

Exploring Advantages and Disadvantages. Exploring the advantages and disadvantages of an automatic thought is a specific way of evaluating the function or utility of various cognitive constructs (Fefergrad & Richter, 2013; Thase, 2013; Wenzel, 2017). Through evaluating the positives and negatives of having an automatic thought, the patient is able to widen their perspective to a more comprehensive and balanced point of view (Freeman, 2006; Freeman &

Davis, 1990). This strategy also allows the patient to think of the short-term and long-term consequences of having the thought (Fennel, 1989; Freeman, 2006). By going through this process, the patient becomes more aware about the costs of continuing with a particular maladaptive way of thinking and is encouraged to adjust to a potentially more adaptive style of thinking (Fefergrad & Richter, 2013; Kellogg & Young, 2008; Wenzel).

Examining Evidence. Examining evidence for a dysfunctional automatic thought is an intervention that tests the empirical validity of the thought (Jarrett & Nelson, 1987; Overholser,

1995; Persons et al., 2001a; Thase, 1995; Williams, 1989; Yovel et al., 2014). Klosko &

Sanderson (1999) and Kellogg and Young (2008) specified the importance of this technique as it encourages the patient to empirically analyze subjective thoughts. When analyzing the thought, the patient is trained to list factual and concrete evidence from their past experiences, while disregarding subjective evidence (Freeman & Davis, 1990; Persons et al., 2001a). The thought is tested to determine if it is distorted or unrealistic (Bieling et al., 2006; Shaw, Katz, & Siotis,

1993). The aim is to weaken the maladaptive thought through considering all the evidence and producing a more realistic or accurate alternative to the original thought (Sudak, 2012; Yovel et al., 2014). To aid in gathering all relevant evidence for or against an automatic thought, this CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 75 technique can be applied in a group setting or with a supportive significant other, which helps gather a full account of the evidence (Bieling et al., 2006; Freeman & Davis, 1990).

Reality Testing. Testing the reality or validity of an automatic thought is a common strategy to challenge and modify cognitions (Covi et al., 1982; Williams, 2004). The patient learns to test and self-correct when they engage in negative evaluations of the self or cognitive distortions (Beck; 1979; Covi et al., 1982). Through testing thoughts, patients undergo an evaluation process that tends to promote balanced or a more realistic perspective (Overholser,

1995; Williams, 2004). Reality testing is often paired with additional techniques such as distancing, examining the evidence, and decatastrophizing (Freeman & Davis, 1990; Williams,

2004).

Reframing. Reframing is a common strategy applied within CBT to modify thinking.

Reframing modifies thoughts to be more specific, temporary and situational rather than global, stable and internal (Freeman & Oster, 1998). Another way of reframing is to turn adversity into advantage where the patient is encouraged to identify the silver lining related to the distressing situation (Freeman & Davis, 1990; Kellogg & Young, 2008). Within this technique the therapist supports the patient in considering an alternative meaning to a difficult situation and promote a more balanced perspective (Dowd, 2004; Freeman, 2006; Freeman & Oster, 1999).

Reattribution. Reattribution is a common strategy applied in CBT where the therapist helps the patient modify their attributional style. A maladaptive attributional style is when the patient attributes difficult experiences to stable, internal and global causes (Dowd, 2004; Sacco

& Beck, 1999) – a style that is prevalent in patients struggling with depression (O’Donahue,

2008). One example of how a patient can have a maladaptive attribution style is when they incorrectly blame the self or others for a specific negative situation (Beck, 1979). In this case, the CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 76 therapist would guide the patient to explore the distribution of blame and logically discuss a more realistic attribution of responsibility more in line with a middle ground (Beck, 1979;

Freeman & Davis, 1990; Freeman & Oster, 1999; Sacco & Beck, 1995; Young et al., 2014).

Decatastrophizing. Decatastrophizing, also referred to as the “what if” technique, is a strategy whereby the therapist challenges a patient’s “catastrophic” or extreme thinking (Covi et al., 1982; Freeman & Davis, 1990). It is commonly applied with patients who struggle with anxiety and is helpful for patients with depression who engage in catastrophizing (Freeman &

Davis, 1990. The validity of these extreme thoughts is explored and the therapist guides the patient to consider information that may have been filtered out such as strengths, previous experiences and adaptive coping mechanisms (Freeman, 2006; Wright et al., 2011), thereby rendering the catastrophic thought more reasonable.

Cognitive Rehearsal. Cognitive rehearsal is a technique that includes both imagery and role-playing, whereby the patient is able to rehearse situations (Williams, 1989). This technique first requires the patient to identify the dysfunctional cognition and then modify that cognition through rehearsal. By rehearsing scenarios, the patient has the opportunity to practice alternative thinking patterns (Wright et al., 2011).

Externalizing Thoughts or Voices. This technique challenges and modifies thoughts through verbalizing the thought (Freeman & Davis, 1990). This strategy presents an opportunity for the patient to externally identify and counter the thoughts that occur from within. As the patient vocalizes their thought, the therapist can model a more adaptive response (Freeman &

Oster, 1998). Through the repeated application of this technique, the patient is able to practice these healthier alternative responses, such that they become part of their internal dialogue

(Freeman & Davis, 1990; Freeman & Oster, 1998). CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 77

Fantasizing Consequences. A closely related strategy to externalizing voices is fantasizing consequences (Freeman & Davis, 1990), as both techniques encourage patients to verbalize their thoughts aloud. However, fantasizing consequences requires the patient to not only voice out the negative thought or situation, but also their predicted consequences of that situation (Freeman & Davis, 1990; Freeman & Oster, 1999). Through this process, the modification of thinking is thought to occur after the patient gains insight into the irrationality of their predicted consequences, which can lead to the development of alternative, more balanced explanations (Knapp & Beck, 2008).

Generating and Examining Alternatives. The therapeutic intervention of generating and examining alternatives enables the patient to consider, evaluate and incorporate additional explanations or viewpoints for an automatic thought (Freeman & Davis, 1990; Freeman & Oster,

1999; Goddard, 1982; Sudak, 2012). This process increases flexibility of thinking and discourages fixation on one way of perceiving an event (Freeman, 2006; Hollon & Garber,

1990). The patient is encouraged to brainstorm (Sacco & Beck, 1995) and consider varying possibilities of an event (Kellogg & Young, 2008; Klosko & Sanderson, 1999) in order to gain a fuller understanding of the situation (Beck, 1979; Young, 2014). Through sensitive, active, and systematic questioning, the therapist begins to evaluate the alternatives in order to modify the original thought to be more accurate (Beck, 1979; Goddard; Overholser, 1995; Thase, 1995;

Young et al., 2014).

Clinical Recommendations.

Clinical Recommendation 1: Use interventions aimed at modifying automatic thoughts in the second phase of treatment after applying identification strategies. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 78

Techniques clustered within the testing or challenging of automatic thoughts are introduced within the second phase of treatment (Freeman & Oster, 1998; Wright et al., 2011; Young et al.,

2014). Young and colleagues (2014) described interventions that challenge or modify maladaptive thoughts are specifically taught within later sessions. Clinical guidelines recommend using identifying techniques first to begin disrupting the automatic thought,

(Freeman & Oster, 1999) and later shifting to the use of modification techniques to replace these thoughts (Fisher & Sprich, 2016; Thase, 1993, 1995). The ordering of modifying interventions has been denoted as a key recommendation for working with automatic thoughts.

Clinical Recommendation 2: Modify automatic thoughts prior to modifying core beliefs. Beck (1979) and Moore and Garland (2003a) suggested that automatic thoughts should be challenged prior to challenging core beliefs, since automatic thoughts are considered to be less stable. Core beliefs are described as deeply ingrained and more stable cognitive constructs that are less apt to change (Beck, 2011). Challenging or modifying automatic thoughts first can feel less threatening to patients with major depression and is believed to produce greater short- term change (Beck, 2011).

Clinical Recommendation 3: Work in collaboration with the patient rather than being overly directive. Another key aspect when applying these techniques is to work in collaboration with the patient. Sacco and Beck (1995) highlighted the drawbacks of the adaptive responses developed by the therapist and noted these tend to be ineffective. Rather, the therapist is encouraged to produce the rational responses with the patient and produce responses that are believable to the patient. Similarly, Freeman and Oster (1998) cautioned the therapists from being overly directive or self-assertive when it comes to relinquishing automatic thoughts tightly connected to the patient’s core beliefs. Hallis and colleagues (2016) noted that this can result in CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 79 the patient resisting cognitive restructuring. Therefore, the therapist should be cognizant and cautious about being overly directive or assertive when it comes to convincing the patient to adopt a more adaptive cognitive response.

Clinical Recommendation 4: Encourage the patient to generate more adaptive alternative thoughts. Freeman and Oster (1999) suggested that the most effective use of alternatives is when the patients themselves capture or suggest an alternative in the moment.

Another effective use of alternatives is when the therapist and the patient collaboratively list alternatives (Overholser, 1995). Alternatively, the therapist can identify or offer multiple alternatives to the therapist; however, this is less effective than having the patient generate the alternatives (Dobson, 2008; Overholser, 1995; Williams, 2004).

Discussion

This scoping review was conducted in order to summarize the cognitive techniques used in CBT to target automatic thoughts in patients with major depression. Techniques targeting automatic thoughts that were repeatedly and commonly described across scientific articles and treatment manuals were uncovered and grouped into three overarching set of techniques: (1) identifying techniques, (2) exploring techniques, and (3) challenging or modifying techniques.

First, a comprehensive definition for each set of techniques was given by reviewing common themes across the techniques comprising of each overarching set. Second, techniques within each set were further detailed and defined. Finally, clinical recommendations regarding the application of the techniques that were uncovered during the scoping review are listed for each set of techniques. The clinical recommendations largely focused on timing of the interventions, ordering of techniques, and suggestions for the therapist to be mindful of such as the collaborative nature of the techniques. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 80

This scoping review has several strengths and limitations. The study contributes to the existing literature, as this was one of the first scoping reviews that summarized all cognitive techniques in CBT for major depression that targeted automatic thoughts. The review provides a typology that has clinical utility for clinicians and trainees. For example, the list of techniques can provide trainees with a definition of individual techniques and information related to how techniques overlap and how similar techniques are distinguished from one another. Moreover, not only does it provide a comprehensive list of techniques, it also provides a summary of clinical recommendations commonly presented in the literature concerning the application of the techniques. For example, this review provides information on the timing and ordering of techniques and suggests how these techniques can be paired. In addition, this paper acts as a centralized, comprehensive, and useful resource for therapists who are interested in applying

CBT techniques with patients with major depression – thus, facilitating the translation of research into practice. Despite these strengths, this scoping review also has some limitations.

First, due to the nature of this scoping review being focused on reviewing a vast database on a widely researched topic – CBT for major depression –, some records may have been missed or omitted during the literature search. However, the risk for that limitation was minimized in this study by having a librarian with expertise in scoping reviews. A second limitation of the study is the risk of bias during thematic analysis and extraction of cognitive techniques. Reviewers were responsible for the grouping of techniques into 3 overarching groups and several core techniques within each group; however, alternative research teams may have classified the techniques differently. Steps were taken to mitigate bias by having more than one individual conduct the review, analysis, and extraction, as well as having an additional reviewer consulted when disagreements arose. Another limitation of the study is that the cognitive techniques reported in CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 81 the review can often overlap with each other in terms of definitions, use, and purpose. For example, the techniques of examining evidence and reality testing within the challenging and modifying group of cognitive techniques are often used concurrently and overlap since they are both techniques that examine the empirical evidence for maladaptive thoughts and aim at modifying them to become more adaptive. We attempted to discuss this in relation to each strategy and described suggestions for clinical applications of these techniques. Additionally, given the large number of records that were reviewed the paper focused on specific questions related to defining and identifying recommendations. This study would have benefited from the explicit review of empirical support for the identified clinical recommendations. In future studies, research directions may benefit from a review of empirical support for the clinical recommendation. Finally, these techniques were extracted from a body of literature that focused on the treatment of major depression; however, many of these strategies have been suggested to be applicable to other disorders (e.g., anxiety; Anderson, Watson & Davidson, 2008). A future review could be conducted to determine how these techniques may generalize to additional disorders.

In sum, this scoping review provides valuable information on cognitive techniques used to target automatic thoughts in individuals with major depression. It groups techniques into three different sets, defines the different techniques within each set, and suggests clinical recommendations for the application of these techniques. This review will prove to be useful for clinicians who have an interest in learning CBT techniques for the treatment of major depression. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 82

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CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 104

Records identified through Additional records identified database searching through other sources (n = 5669) (n = 22) *

Identification

Records after duplicates removed (n = 4517)

Screening Records screened Records excluded (n = 4517) (n = 4326)

Full-text articles excluded, Full-text articles with reasons ity assessed for eligibility (n = 191) (n = 86) Intervention-related = 46 Disorder or medical Eligibil condition = 22 Non-adult population = 6 Duplicate references = 4 Theoretical orientation or topic out of scope = 4 Source = 3

Studies included in Language = 1 qualitative synthesis (n = 105)

Included 105)

Figure 1. PRISMA1 Flow Diagram. This figure shows the flow chart of the scoping review

(Moher et al., 2009).

1 PRISMA stands for Preferred Reporting Items for Systematic reviews and Meta-Analyses. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 105

Appendix A

Embase Search Results

# Search Statement Results

1 Cognitive Restructur*.mp. 1222

2 Cognitive Intervention*.mp. 1215

3 Cognitive Technique*.mp. 259

4 Cognitive Strateg*.mp. 1537

5 cognitive component*.mp. 1338

6 cognitive method*.mp. 156

((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique$ or 7 27602 modif* or strateg* or component*)).tw.

8 1 or 2 or 3 or 4 or 5 or 6 or 7 27732

9 DEPRESSION/ 319381

10 AGITATED DEPRESSION/ 276

11 ATYPICAL DEPRESSION/ 545

12 DEPRESSIVE PSYCHOSIS/ 1312

13 DYSPHORIA/ 5542

14 DYSTHYMIA/ 8080

15 ENDOGENOUS DEPRESSION/ 1219

16 INVOLUTIONAL DEPRESSION/ 471

17 MAJOR DEPRESSION/ 53347

18 MASKED DEPRESSION/ 51

19 MELANCHOLIA/ 3325

20 MOURNING SYNDROME/ 121

21 ORGANIC DEPRESSION/ 54

22 POSTOPERATIVE DEPRESSION/ 165

23 PREMENSTRUAL DYSPHORIC DISORDER/ 1131

24 PSEUDODEMENTIA/ 460

25 PUERPERAL DEPRESSION/ 8272 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 106

26 REACTIVE DEPRESSION/ 431

27 RECURRENT BRIEF DEPRESSION/ 50

28 SEASONAL AFFECTIVE DISORDER/ 1215

29 EMOTIONAL DISORDER/ 16028

30 MOOD DISORDER/ 37715

31 AFFECTIVE NEUROSIS/ 11525

32 BLUNTED AFFECT/ 646

33 MAJOR AFFECTIVE DISORDER/ 375

34 MINOR AFFECTIVE DISORDER/ 53

9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 35 421735 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34

36 cognitive therapy/ 42039

37 cognitive behavioral therapy/ 4591

38 CBT.mp. 12998

(cognitive adj3 therap$).mp. [mp=title, abstract, heading word, drug trade name, original 39 title, device manufacturer, drug manufacturer, device trade name, keyword, floating 53186 subheading word]

40 Psychotherapy/ 91457

41 psychotherap$.tw. 59510

42 psycho-therap$.tw. 287

43 36 or 37 or 38 or 39 or 40 or 41 or 42 153170

44 8 and 35 and 43 1784

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 107

Appendix B

Ovid Search Results # Search Statement Results

1 cognitive restructuring.mp. 753

2 cognitive strategy.mp. 316

((cognitive or cognition) adj3 (restructur$ or intervention$ or method$ or technique$ or 3 15510 modif$ or strateg$ or component$)).tw.

4 1 or 2 or 3 15518

5 Mood Disorders/ 12934

6 Affective Disorders, Psychotic/ 2197

7 Depressive Disorder/ 67564

8 Depression, Postpartum/ 4559

9 Depressive Disorder, Major/ 25423

10 Depressive Disorder, Treatment-Resistant/ 779

11 Dysthymic Disorder/ 1093

12 Seasonal Affective Disorder/ 1161

13 Neurotic Disorders/ 17930

14 DEPRESSION/ 99699

15 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 215796

16 CBT.mp. 8536

17 cognitive behavioral therapy/ 21341

18 (cognitive$ adj3 therap$).mp. 29697

19 Psychotherapy/ 51145

20 psychotherap$.tw. 37894

21 psycho-therap$.tw. 104

22 16 or 17 or 18 or 19 or 20 or 21 97037

23 4 and 15 and 22 778

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 108

Appendix C

PsycINFO Search Results # Search Statement Results

1 exp Cognitive Restructuring/ 726

2 cognitive restructur*.mp. 2460

3 Cognitive Intervention*.mp. 1434

4 exp Cognitive Techniques/ 15275

5 cognitive technique*.mp. 2027

6 Cognitive Strateg*.mp. 3089

7 cognitive modification*.mp. 142

8 cognitive component*.mp. 1948

((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique* or 9 30039 modif* or strateg* or component*)).tw.

10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 40970

11 exp Major Depression/ 116377

12 exp Anaclitic Depression/ 56

13 exp Dysthymic Disorder/ 1454

14 exp Endogenous Depression/ 1223

15 exp Postpartum Depression/ 4154

16 exp Reactive Depression/ 292

17 exp Recurrent Depression/ 746

18 exp Treatment Resistant Depression/ 1954

19 exp Atypical Depression/ 188

20 exp "Depression (Emotion)"/ 24113

21 exp Seasonal Affective Disorder/ 1021

22 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 140108

23 exp Cognitive Behavior Therapy/ 17971

24 CBT.mp. 11841

25 (cognitive adj3 therap$).mp. 38733 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 109

26 psychotherapy/ 47724

27 psychotherap$.tw. 103484

28 psycho-therap$.tw. 146

29 23 or 24 or 25 or 26 or 27 or 28 143427

30 10 and 22 and 29 3074

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 110

Linking Manuscripts One and Two

In manuscript one (Chapter two) a scoping review was conducted where existing records on techniques for automatic thoughts in major depression were explored. Techniques were grouped into three core groups of techniques: (1) identifying techniques, (2) exploring techniques, and (3) challenging or modifying techniques. Each group of techniques and individual techniques were defined and clinical recommendations were uncovered. Some themes uncovered related to clinical recommendations included timing of the interventions and ordering of techniques. Strengths and limitations were reviewed. The clinical implications were discussed and future research endeavors were suggested.

Manuscript two (Chapter three) will present the results of the scoping review that pertain to cognitive interventions that target core beliefs. Among manuals core belief techniques were distinguished from automatic thought interventions. The following manuscript will narrow in on techniques that focus on these more ingrained and unconscious cognitive structures. Core belief techniques will also be grouped into categories according to how they are identified in the research studies and clinical manuals. Clinical recommendations will also be identified and described, and research and clinical implications will be discussed. These two manuscripts taken together will present a multitude of available cognitive interventions pertaining to automatic thoughts and core beliefs.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 111

Chapter 3 - Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of

Cognitive Interventions Targeting Core Beliefs in Major Depression

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 112

Running head: THERAPIST TECHNIQUES FOR CORE BELIEFS

Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of Cognitive

Interventions Targeting Core Beliefs in Major Depression

Amanda R. Sheptycki, Emma Schmelefske, Emily Kingsland, Imy Shenouda, & Martin Drapeau

McGill University

Address Correspondence to Dr. Martin Drapeau, SAPP Lab-McGill, 3700 McTavish,

Montreal, Quebec, H3A 1Y2; email: [email protected]

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 113

Abstract

Cognitive behavioural therapy for depression includes cognitive and behavioural techniques to target depressive symptoms. Cognitive techniques are often separated into interventions that target automatic thoughts and core beliefs (Wright, Basco & Thase, 2006a; Wright, Basco &

Thase, 2006b). Core belief interventions have been described for decades, including defining interventions and outlining recommendations for treatment. However, a consolidated review of the available material across books, treatment manuals and empirical studies has yet to be completed. This review attempts to identify and define core belief techniques and describe core treatment recommendations in the treatment of major depression. A literature search was completed in three databases including PsychINFO, EMBASE and Medline. The methodology followed guidelines outlined by Arksey and O’Malley (2005) and the thematic analysis framework established by Braun and Clarke (2006). The review uncovered two clusters of core belief-related techniques: identifying techniques and modifying techniques. Recommendations related to each cluster of techniques were delineated. Implications for future research and clinical practice were discussed.

Keywords: Cognitive interventions, therapist techniques, core beliefs, CBT, cognitive behavior therapy, major depression

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 114

Therapist Techniques in Cognitive Behavioural Therapy: A Scoping Review of Cognitive

Interventions Targeting Core Beliefs in Major Depression

There are a several interventions applied within Cognitive Behavioural Therapy (CBT) for the treatment of patients with major depression. Two broad and highly common clusters of techniques that are detailed within treatment manuals are behavioural activation, and cognitive interventions (Kanter & Puspitasari, 2012; Leahy & Rego, 2012; Young, Rygh, Weinberger, &

Beck, 2001). Behavioral activation generally involves helping the patients to schedule activities that are positively reinforcing (Kanter & Puspitasari, 2012), whereas cognitive interventions are those that target different cognitive constructs such as automatic thoughts and core beliefs.

Automatic thoughts are unstable, temporary and typically situation-specific and are often more reflexive in nature (Beck, 1976, 1979; Freeman & Oster, 1998; Kwon & Oei, 1994). These thoughts tend to be more accessible compared to more unconscious underlying core beliefs. On the other hand, core beliefs, are described as deeply ingrained beliefs that are often stable and cross-situational (Beck, Freeman et al., 1990; Beck, 2011; de Oliveira, 2012; Freeman & Leaf,

1989; Kwon & Oei, 1994). These beliefs tend to develop from early significant experiences

(Berk, 2004; de Oliveira, 2012). From a cognitive behavioural perspective, these negative core beliefs are associated with making the patient more cognitively vulnerable to depression.

For decades, CBT treatment manuals have included core belief-focused techniques and considered them as a fundamental component of cognitive techniques (Jacobson et al., 1996,

McBride, Farvolden, & Swallow, 2007). Wright, Basco, Ramirez and Thase (2006) deemed techniques that focus on core beliefs important in working with major depression, as these CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 115 techniques are believed to alleviate depressive symptomology and act to prevent the impact of future stressors. Further, Alloy, Peterson, Abramson and Seligman (1984) highlighted the importance of targeting maladaptive core beliefs as they may act as a barrier to seeking treatment, which may in turn act to keep the patient stuck and unmotivated to improve their functioning. Beliefs that are held as facts without disputation can be strengthened over time and when activated can lead to a negative mood, or a depressive episode (Mor & Haran, 2009).

Newman (2008) argued that it is important to address core beliefs that pertain to attribution of positive events to external causes as this can encourage the patient to take personal credit for positive events and reduce vulnerability to future depressive episodes (Hollon, Derubeis, &

Seligman, 1992). Altering and shifting beliefs to be more flexible through the use of cognitive techniques can be a central aspect to the treatment and prevention of mood disorders.

Techniques that target core beliefs are often applied concurrently with techniques that target automatic thoughts. Many techniques act simultaneously on both levels of cognitions

(Freeman & Oster, 1998; Freres & Gillham, 2006). These include techniques such as Socratic

Questioning and examining the evidence for and against a thought or belief. Both of these techniques ultimately tend to explore an irrational negative thought and logically determine the acceptability of an alternative belief. Therefore, both can be used to challenge either automatic thoughts or core beliefs. However, there are interventions that appear to be more specific to core beliefs, such as the downward arrow technique. Although previous reviews have explored behavioural activation strategies (Kanter et al., 2010) and automatic thoughts (Sheptycki et al.,

2020), a current review does not exist that explores core beliefs. Given the significance of core belief-specific techniques, the extensive available literature base, and the importance of these underling structures in the development and maintenance of depression, it is important to CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 116 complete a comprehensive review to address this gap in the literature. Completing this review will benefit practitioners, trainees, training programs and continue to build on the existing research.

Hence, the present review aimed to identify core cognitive treatment strategies that target core beliefs in major depression within CBT. A second purpose of the review was to delineate clinical recommendations commonly suggested for applying these techniques within this population. The overarching purpose of this review is to provide researchers and practitioners with a comprehensive review of core strategies and clinical recommendations that would aid them in targeting the core beliefs of individuals with major depression using CBT. Future research can then further examine the empirical evidence for these techniques and clinical recommendations, ultimately aiding in providing more consistent guidelines for practitioners.

Method

This study is a part of a larger review that aimed to identify techniques that target cognitive constructs within a CBT framework for major depression. Given the extensive literature on CBT cognitive interventions, the current review focused on cognitive techniques applied specifically to core beliefs.

This scoping review followed the framework developed by Arksey and O’Malley (2005).

The five steps included in this framework consist of: (1) identifying the research question, (2) identifying relevant studies, (3) selection of studies, (4) charting the data, and (5) collating, summarizing and reporting the results. While completing the 5th step of the framework, a thematic analysis was conducted and followed the six phases delineated by Braun and Clarke

(2006). These phases included familiarizing yourself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 117

Following the Arksey and O’Malley (2005) framework, the research questions were first defined. The questions addressed in this paper as applied to core beliefs in the treatment of major depression in adults included (1) What are the CBT techniques that focus on core beliefs?; (2)

How are these therapeutic techniques defined?; and (3) What are common clinical recommendations for delivering these therapeutic techniques?.

The second step of the framework consisted of identifying the relevant studies for the scoping review. To do that, a research librarian with expertise in scoping reviews was consulted.

A search string was developed based on previous searches used in empirical studies and similar scoping reviews. Key terms pertaining to cognitive techniques, CBT treatment manuals, types of empirical studies and major depression were included in the search strategy (see Appendix A through C). The literature search was performed in three electronic databases, PsychINFO,

Embase and Medline, between 1964 to 2018 by two graduate students and one senior researcher.

The search was conducted between March 6th and March 8th 2018. In order to ensure that records such as treatment manuals and book chapters were also included in the scoping review, a hand search was also completed in McGill University’s World Catalogue, in addition to the electronic database search aforementioned. Moreover, reference lists of identified studies and manuals were reviewed to include additional potentially relevant articles in the review. The search resulted in a large number of records (n =5669) for potential use within this scoping review (see Figure 1) and are charted using PRISMA guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009).

The third step of the framework consisted of selecting the studies. The selection of studies was performed by two graduate students in counselling psychology who had previous clinical training in CBT, as well as in conducting scoping and systematic reviews. The reviewers met regularly to select studies and consulted a third reviewer whenever disagreements occurred. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 118

The revision started off with removing duplicates, resulting in 4,517 records. Next, results were reviewed at the abstract and full-text level. The selection of studies at each step was performed according to seven pre-determined inclusion and exclusion criteria which include criteria on population type, disorder or medical condition, intervention type, orientation, discipline, source and language. Specifically, records were included if they were English peer-reviewed articles, manuals, handbooks, facilitator’s guides, and theoretical books that focused on adult populations

(e.g., age 18 to 64 years of age), major depressive disorders, and CBT therapist techniques that target cognition. Considering the wealth of literature surrounding this topic area, the search did not include grey literature. The abstracts of these records were reviewed (n = 4517), narrowing down the records that were selected and read in full-text (n = 191). From these records, 105 were selected for incorporation in the review (see Figure 1).

The fourth step of the framework consisted of charting the data from the selected records.

This step was performed by four reviewers. Data extraction consisted of extracting the following information from the selected records: publication type, patient diagnosis, treatment type, duration, number of sessions, demographics, and study design (See Appendix A in Supplemental materials).

The fifth and final step consisted of collating, summarizing, and reporting the results. In this step, the thematic analysis was conducted. To manage inter-rater reliability, both raters reviewed approximately 30% of records. Consistent with a similar study conducted by Kanter and colleagues (2010), an Intra-Class Coefficients (ICC) was not calculated given the qualitative nature of the study. However, two reviewers completed independent ratings and if disagreement occurred, a third reviewer was available. Reviewers familiarized themselves with the records (n

=105) and met regularly to generate initial codes. Initial codes are basic elements of information CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 119 that are relevant to the search or meaningful to the researcher; they were used to identify content within the records. The codes were then sorted and collated into themes and sub-themes. After re-examining the themes for coherence and comprehensiveness, the reviewers defined the themes and sub-themes. Finally, an analyst generated a report where the themes were described and supported by evidence, as detailed below.

Results

The scoping review and thematic analysis resulted in the generation of two broad themes, consisting of two overarching groups of cognitive techniques: (1) techniques that identify core beliefs, and (2) techniques that aim to modify core beliefs. Those two themes were further divided into several sub-themes of individual techniques. Moreover, the thematic analysis uncovered a theme of clinical recommendations pertaining to the application of the techniques.

In this scoping review, the overarching group of identifying core belief techniques will be first defined, as well as the individual techniques within that group. Second, the overarching group of modifying core belief techniques will be defined, as well as the individual techniques within that group. Lastly, the clinical recommendations pertaining to the application of the techniques will be outlined and discussed.

Techniques to Identify Core Beliefs

Definition. Techniques that identify core beliefs are those that aid the patient in recognizing and pinpointing these deeply engrained core beliefs. In order to identify core beliefs, the therapist guides the patient to use multiple techniques from early in the therapeutic process to monitor accessible beliefs that are consistent across situations. Identification strategies assist the patient in reflecting or engaging in self-inquiry related to the meaning of a belief (Hollon &

Garber, 1990). Another element closely linked to identifying core beliefs is the exploration of CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 120 these beliefs and developing a deeper understanding of the meaning linked to a belief (Evans &

Hollon, 1988; Freeman & Davis, 1990). It is important to note that the identification of core beliefs begins to occur through the process of exploring automatic thoughts (Sacco & Beck,

1995). Techniques applied to the identification of automatic thoughts are similar to techniques denoted as integral to the identifying of a core belief. The core strategies used for identifying core beliefs consist of: historical context, downward arrow, and the use of inventories and worksheets that identify underlying core beliefs.

Historical context. Reviewing a patient’s historical context for underlying beliefs is noted as a key strategy in identifying core beliefs (Berk, Henriques, Warman, Brown, & Beck,

2004; McBride et al., 2017; Wright et al., 2006b). Berk and colleagues (2004) defined this process as exploring and discussing memories, and early formative experiences and impactful relationships and events to discern maladaptive and adaptive beliefs (Wright et al., 2006b). The therapist guides the patient to identify patterns across situations, people, mood states, and events.

An important aspect to this technique is providing psychoeducation on the process of attributing meaning to past events and how people often develop rules for encoding information

(Overholser, 1995). With the help of a therapist, these past events are then systematically reviewed for commonalities in meanings (Dobson, 2008). Wright et al. (2006b) described it is common to incorporate guided discovery and questioning to detect recurring themes and explore about impact of significant figures, culture, socialization, interests, jobs, values and activities

(Weight et al., 2006b).

Downward arrow. The downward arrow technique has been denoted as a core and effective strategy for identifying core beliefs and assumptions (Sacco & Beck, 1995; Thase,

1995). This technique consists of a process of consecutive repeated questioning that increases the CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 121 depth from an initial automatic thought to the underlying core belief (Bieling et al., 2006; Wright et al., 2006b;). Questions such as “if this were true, what would it mean?” are initially directed at a conscious and accessible thought; the clinician then proceeds to ask the question repeatedly in response to each given answer (Freeman, 2006). Through careful questioning, deeper meaning is elicited that enables the patient to delve into a fundamental belief or conviction (Sacco & Beck,

1995). The series of questions continues until the core maladaptive belief is ascertained (Wenzel,

2017). Fefergrad and Richter (2013) explained that this process often elicits strong affect from the patient when the belief is identified. Therefore, this technique can also be used to identify the emotion closely associated with the core belief (Thase, 2013). Moreover, this therapeutic strategy can assist in uncovering meaning, determining implications of events, and enhancing the therapeutic alliance (Dobson, 2008; Fefergrad & Richter, 2013).

Inventories and worksheets. An additional approach to identifying core beliefs is through the use of inventories and worksheets. Given the nature of core beliefs being deeply ingrained and difficult to access, the use of an inventory can be very helpful in discerning core beliefs (Freeman & Oster, 1998; Wright et al., 2006b). Wright and colleagues (2006b) explained that the administration of assessment tools such as inventories or worksheets that identify common core beliefs can provide a level of insight that may not be easily or directly observed otherwise. O’Donahue (2008) suggested incorporating the use of measures such as the

Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978), Personality Beliefs

Questionnaire (PBQ; Beck et al., 2001) and Young Schema Questionnaire (YSQ; Schmidt,

Joiner, Young, & Telch, 1995) when identifying core beliefs. These inventories provide examples of core beliefs that allow the patient to reflect on how well they can relate to these suggested core beliefs and also think about their own underlying beliefs (Roberts & Hartlage, CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 122

1996; Wright et al., 2006b). These inventories also allow patients to draw contrasts between adaptive core beliefs and maladaptive core beliefs. The scales can provide a more comprehensive array of understanding the complexity of underlying cognitive processes in the patient (Wright et al., 2006b).

Techniques to Modify Core Beliefs

Definition. Techniques that modify core beliefs have been described as a fundamental set of strategies within CBT (Roberts & Hartlage, 1996). Modifying techniques tend to consist of ones that examine, test, challenge and correct maladaptive beliefs of the self, others and the world (Roberts & Hartlage, 1996; Wenzel, 2017). Frojan-Parga and colleagues (2009) noted that techniques used to modify automatic thoughts in CBT can also be applied to modify more deeply ingrained assumptions and core beliefs. Scholars note that the goal of modifying techniques is to restructure rigid and unrealistic core beliefs to a cognitive system that is more flexible and more in line with reality (Evans & Hollon, 1988; Persons et al., 2001b; Rush, 1983; Shaw et al., 1993).

Freeman and Oster (1999) further stated that the goal is not to eradicate the beliefs but to reshape and shift them to be less extreme and have a more balanced perspective (Hallis et al., 2016;

Persons et al., 2001b). Modifying interventions for beliefs consist of guidance from the therapist to activate a patient’s metacognitive skills (Freeman & Oster, 1998). The techniques used for modifying core beliefs include examining evidence, advantages and disadvantages, historical test, continuum method, alternative beliefs and positive data log.

Examining evidence. Examining the evidence is a core strategy applied to core beliefs.

Moore and colleagues (2003b) suggested this is a key strategy to begin weakening beliefs and reduce the absolute acceptance of them (O’Donahue, 2008). This technique requires patients to systemically and objectively identify evidence for and against a certain maladaptive core belief, CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 123 thereby calling into question the accuracy of their initial core belief (Hollon & Garber, 1990).

The patient is guided to reduce their perseveration on the maladaptive core belief, increase the use of the objective approach, and build upon the evidence against the maladaptive core belief

(Evans & Hollon, 1988; Moore et al., 2003b; Wright et al., 2006b). With this technique, the patient is encouraged to identify evidence from their own experiences (O’Donahue, 2008), examine implications or consequences of holding the maladaptive belief (Dobson & Jackman-

Cram, 1996; Hollon & Garber; Piasecki & Hollon, 1987), and assess the belief from many perspectives (Covi et al., 1982; Thase, 1993; Wright et al., 2006b).

Exploring the advantages and disadvantages. A strategy related to and often used with examining evidence is exploring the advantages and disadvantages of holding certain beliefs and assumptions (Longmore & Worrell, 2007). Moore and colleagues (2003b) described this technique as an important strategy and initial step in modifying a belief. This technique requires an explicit listing of the advantages and disadvantages of holding both specific adaptive and maladaptive beliefs, and of changing beliefs (Moore et al., 2003; Sudak, 2012). The patient will then have a written record which can assist them in informing the core belief change process

(Covi et al., 1982; Wright et al., 2006b). Exploring the advantages and disadvantages allows the patient to participate in a cost-benefit analysis where they can analyze the relative weight of both sides and assess the short and long-term implications of holding a core belief (Moore et al.,

2003b; Thase, 1993).

Using historical tests. An additional technique that is related to and is often applied with examining the evidence for and against a core belief is the technique of using historical tests.

Berk and colleagues (2004) suggested that when exploring the evidence, it is important to also focus on early origins of each belief. This is intended to work as a way to begin to establish more CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 124 adaptive beliefs and responses. The therapist and patient collaborate on reviewing the existing history and examining how specific instances, such as key events, specific time periods, and discrete developmental periods, may undermine the maladaptive core belief (McBride et al.,

2017; Moore et al., 2003b; Padesky, 1994; Persons et al., 2001b). Persons and colleagues

(2001b) suggested concluding the historical review by summarizing the confirming and disconfirming information for the core belief, thus giving the patient an opportunity to develop a more adaptive and increasingly flexible perspective.

Continuum method. McBride and colleagues (2017) identified the continuum method as a core technique to shift absolutist beliefs to a more balanced view. Persons and colleagues

(2001b) noted that patients with depression tend to hold core beliefs that are global and extreme in nature. This technique allows patients with depression to notice the polarity of thinking and adopt a more dimensional approach to thinking (McBride et al., 2017; Persons et al. 2001b;

Wright et al, 2006b.). Techniques such as examining the evidence or questioning can be applied with this technique to aid in shifting evaluations of the self towards a more adaptive or balanced stance (McBride et al., 2017).

Alternative beliefs. This technique is described as assisting the patient in developing or building upon alternative beliefs (Jacobson et al., 2000; Moore et al., 2003b). The strategy consists of creating a list of plausible and adaptive beliefs that would replace the adaptive beliefs

(Dobson, 2008; Freeman & Oster, 1999; Wright et al., 2005b). It must be noted that developing alternatives is not simply about thinking positively and substituting negative core beliefs with positive alternatives (Moore et al., 2003b). In fact, it is about enhancing flexibility and encouraging additional ways of responding. Alternative belief strategies aim to influence the foundational or basic rules that guide the patient’s thinking (Wright et al., 2005b). When CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 125 considering alternate beliefs, the patient is attending to information that may have initially been filtered out or missed while developing the maladaptive belief; therefore, this technique can provide with information that will counteract maladaptive beliefs and strengthen adaptive beliefs

(Moore et al., 2003b). Aiding in this process, the advantages and disadvantages technique can be used to help the patient consider the short and long term implications of the initial and alternate beliefs (Dobson, 2008). An additional technique that can be used is the as if technique where the patient imagines what thoughts they would have if they adopted the alternative belief (Dobson,

2008). This provides an opportunity for the patient to examine current or potential experiences through the lens of the alternative rules or beliefs (O’Donahue, 2008b).

Positive data log. A positive data log is a technique applied in order to modify a maladaptive core belief into a positive or more balanced core belief (Sudak, 2012). After the core belief is identified and clearly stated, ideally in the patient’s terms, this technique involves the patient and therapist collaboratively developing a data log of evidence that supports the new core belief (Persons et al., 2001b; Wenzel, 2017). The data log increases the awareness and monitoring of events that are consistent with the new core belief. The patient is tasked with pro- actively identifying information that clearly supports the new belief, encouraging the patient to notice data that may have been previously viewed as small or insignificant (McBride et al.,

2017). At the same time, the clinician encourages the patient to notice when they are discounting or resisting information that is incompatible with the more absolute or old maladaptive core belief (McBride et al., 2017; Padesky, 1994). This approach is also believed to assist in reducing the absolute nature of initial maladaptive core belief (McBride et al., 2017).

Clinical Recommendations for the Application of Techniques Targeting Core Beliefs CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 126

Clinical recommendations pertaining to the use of techniques targeting core beliefs are commonly highlighted across CBT treatment protocols for major depression. Most clinical recommendations that were compiled in this scoping review are primarily focused on the recommended timing of these techniques and particular caveats related to the nature of these ingrained structures. Another line of clinical recommendations that were commonly referenced are specific to techniques directed at identifying core beliefs and working with adaptive compared to maladaptive core beliefs.

Clinical Recommendation 1: Apply core belief strategies after depressive symptomology has subsided. When it comes to the use of core belief techniques in major depression, timing is central to the application. Careful consideration must be given to the severity of depressive symptoms since core belief techniques are recommended to be used only when symptomology has begun to reduce (Sacco & Beck, 1995). As treatment progresses and depressive symptomology begins to ameliorate, the patient is thought to have developed enhanced resilience that is conducive to greater readiness for core belief work (Dobson, 2008).

Dobson further advised that applying these techniques prematurely can be linked with a worsening of symptoms. Considering the level of depression in determining appropriateness of the intervention is suggested as a critical in this process of clinical decision-making.

Clinical Recommendation 2: Incorporate core belief interventions in later phases of treatment. Work related to both identifying and modifying core beliefs was consistently recommended during the later phases or end of treatment (Dobson, 2008; Mor & Haran, 2009;

O’Donahue, 2008; Sacco & Beck, 1995). One exception for the inclusion of core belief work earlier in psychotherapy is related to case formulation. O’Donahue (2008) discusses the importance of identifying core beliefs in early phases to inform the case conceptualization and CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 127 treatment planning process. The overarching clinical recommendation indicates the importance of timing, which is consistent across studies and manuals, and through earlier and more current records (Dobson, 2008; Rush, 1983).

Clinical Recommendation 3: Apply core belief interventions once there is a strong therapeutic alliance. Another recommendation is to apply these techniques in the context of a strong therapeutic relationship. Wright and colleagues (2006b) indicated that elements integral to strong rapport such as expressing empathy and acceptance are factors that can facilitate and ease the identification and modification of these more ingrained cognitive structures.

Clinical Recommendation 4: Provide psychoeducation, and normalize the slow and gradual shifting of core beliefs. Sudak (2012) noted the challenging nature of working with core beliefs as they are often deeply embedded into the identity of the patient and have been reinforced for years during the course of the patient’s life (Wright et al., 2006b). Freeman and

Davis (1990) identified when modifying core beliefs, beliefs that are less compelling are often more apt to modifications. These less ingrained core beliefs are more likely to shift with testing and modification techniques. Moore and colleagues (2003b) emphasize the importance of providing psychoeducation to the patient on the slow process of change. Knowing that patients who struggle with depression have a tendency to engage in cognitive errors where they evaluate themselves negatively, normalizing this gradual shift in cognition will discourage them from attributing the slow progress to faults in the self.

Clinical Recommendation 5: Identify core beliefs through the use of multiple techniques. It is recommended that therapists incorporate a variety of techniques when it comes to identifying core beliefs (O’Donahue, 2008; Wenzel, 2017). Wright and colleagues (2006b) noted that identifying core beliefs can occur through a developmental review of interpersonal CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 128 relationships, significant events, or circumstances that are central themes or topics. Additional recommendations for uncovering core beliefs are through the administration of inventories, particularly when the patient is observed to have difficulty with noticing core beliefs. Through the use of inventories both positive and negative core beliefs can be identified that may have been previously dormant or difficult to detect. Other scholars have recommended identifying core beliefs through attending to language used such as use of verbs including should (Roberts &

Hartlage, 1996) and through noticing moments of strong affect (Wenzel, 2017).

Clinical Recommendation 6: Focus on both adaptive and maladaptive core beliefs, as well as on a limited number of beliefs related to the presenting problem. When working on core beliefs, Persons and colleagues (2001b) recommend selecting one to two core beliefs that appear most closely related to the patient’s presenting problems. The idea is to utilize interventions that attend to a select number of core beliefs. Moreover, it is recommended that the therapist also tend to the adaptive aspects of the patient’s underlying cognitive structures, and not just the maladaptive core beliefs (Wright et al., 2006b). Shifting attention to more adaptive core beliefs can be a more effective way of producing core belief change (McBride et al., 2017).

Dobson (2008) suggested that the focus on adaptive or developing of a more adaptive core belief should be a belief that is important and attainable to the patient.

Discussion

This review focused on identifying cognitive techniques that target core beliefs, and delineating clinical recommendations pertaining to their use. Therapist techniques applied in the treatment of major depression were reviewed from various manuals, book chapters and empirical studies. These interventions were grouped into two clusters: (1) techniques that identify core beliefs and (2) techniques that modify core beliefs. Common identifying techniques applied to CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 129 core beliefs included historical context, downward arrow and inventories and worksheets. On the other hand, techniques directed at core belief modification included examining evidence, advantages and disadvantages, historical tests, continuum method, alternative beliefs and positive data log. In addition, the review identified a number of clinical recommendations for applying core belief-focused interventions. These recommendations included: applying techniques after there has been a reduction in depressive symptomology, towards the end of treatment, and in the context of a strong therapeutic relationship. Recommendations unearthed also included normalizing the gradual shifting of core beliefs and applying a variety of techniques to identify beliefs. Lastly, the review identified the importance of identifying maladaptive and adaptive beliefs and focusing on a select number of core beliefs.

The present review has several strengths and limitations. With regards to this study’s strengths, it is one of the first reviews to summarize the cognitive techniques used in CBT that target core beliefs in major depression. Not only does it detail the cognitive techniques, but it also provides a list of recurrent clinical recommendations found in the literature that explain how to apply the cognitive techniques. Therefore, this review combines a wealth of theoretical and practical knowledge pertaining CBT cognitive techniques targeting core beliefs. Consequently, this scoping review serves as a very useful tool for both clinicians and researchers. Clinicians can refer to this review to apply the techniques and clinical recommendations in their practice, while researchers can use it as a basis to conduct further research regarding the empirical support for these techniques and recommendations, and further refining them.

Despite the strengths of the study, several limitations can be noted. Firstly, this review is focused on an area of research that has been extensively published; therefore, the literature search may have not included all possible relevant records that exist. To minimize the risk of CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 130 having omitted any records, reference lists of publications were reviewed and experts were consulted. Secondly, due to the vast array of cognitive interventions that exist in CBT literature, we did not include more generalized cognitive techniques or those that were specific to working with automatic thoughts (the latter were addressed in Sheptycki, Schmelefske, Kingsland, Azzi,

& Drapeau, 2020). In order to capture the full array of techniques, a separate manuscript will focus on these additional techniques. Thirdly, there may have been a risk of bias during the extraction of the cognitive techniques and conduction of the thematic analysis; it is possible that other reviewers would have examined the available records differently. To mitigate this limitation, more than one reviewer was included in all steps of the process, thus increasing objectivity and decreasing bias. For instance, the second reviewer independently extracted cognitive techniques to reduce bias. A final limitation of the study is that the clinical recommendations may lack specificity, rendering the application of the clinical recommendations more challenging. For example, the second recommendation suggesting the incorporation of core belief interventions in the later phases of treatment, does not provide empirical evidence detailing the specific timing that is recommended. Future research can focus on providing more detailed indices of reference (e.g. the session number) when providing clinical recommendations regarding topics such as timing of interventions.

Conclusion and Future Research

Cognitive techniques targeting core beliefs have been identified as important in the treatment of major depression. Attending to core beliefs has been argued to enhance knowledge about the self and provide an impetus for change (Sudak, 2012). This review aimed to provide a systematic listing of techniques and begin to establish core treatment recommendations. These techniques and recommendations are commonly referred to across treatment manuals and peer- CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 131 reviewed records. However, there appears to be a paucity of studies that examine these techniques and their effectiveness with reducing depressive symptomology. Follow-up research could examine individual techniques and the pairing of techniques to determine the effectiveness of the techniques and their relevance within CBT treatment protocols. Other future directions may be to begin uncovering existing empirical support for the clinical recommendations compiled in this review and test the efficiency of each. Most studies related to CBT focus on a quantitative analysis (Day, Thorn & Kapoor, 2011) and researchers have advised the importance of incorporating qualitative analyses in order to enrich and further understand therapeutic techniques (Berg, Raminani, Greer, Harwood, & Safren, 2008). This study demonstrated the importance of a scoping review to carefully uncover and clearly demonstrate the need for further studies to more systematically test these recommendations prior to implementing them in clinical practice.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 132

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Records identified through Additional records identified database searching through other sources (n = 5669) (n = 22) *

Identification

Records after duplicates removed (n = 4517)

Screening Records screened Records excluded (n = 4517) (n = 4326)

Full-text articles excluded, Full-text articles with reasons ity assessed for eligibility (n = 191) (n = 86) Intervention-related = 46 Disorder or medical Eligibil condition = 22 Non-adult population = 6 Duplicate references = 4 Theoretical orientation or topic out of scope = 4 Source = 3

Studies included in Language = 1 qualitative synthesis (n = 105)

Included 105)

Figure 1. PRISMA2 Flow Diagram. This figure shows the flow chart of the scoping review (Moher et al., 2009).

2 PRISMA stands for Preferred Reporting Items for Systematic reviews and Meta-Analyses. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 154

Appendix A

Embase Search Results

# Search Statement Results

1 Cognitive Restructur*.mp. 1222

2 Cognitive Intervention*.mp. 1215

3 Cognitive Technique*.mp. 259

4 Cognitive Strateg*.mp. 1537

5 cognitive component*.mp. 1338

6 cognitive method*.mp. 156

((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique$ or 7 27602 modif* or strateg* or component*)).tw.

8 1 or 2 or 3 or 4 or 5 or 6 or 7 27732

9 DEPRESSION/ 319381

10 AGITATED DEPRESSION/ 276

11 ATYPICAL DEPRESSION/ 545

12 DEPRESSIVE PSYCHOSIS/ 1312

13 DYSPHORIA/ 5542

14 DYSTHYMIA/ 8080

15 ENDOGENOUS DEPRESSION/ 1219

16 INVOLUTIONAL DEPRESSION/ 471

17 MAJOR DEPRESSION/ 53347

18 MASKED DEPRESSION/ 51

19 MELANCHOLIA/ 3325

20 MOURNING SYNDROME/ 121

21 ORGANIC DEPRESSION/ 54

22 POSTOPERATIVE DEPRESSION/ 165

23 PREMENSTRUAL DYSPHORIC DISORDER/ 1131

24 PSEUDODEMENTIA/ 460

25 PUERPERAL DEPRESSION/ 8272 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 155

26 REACTIVE DEPRESSION/ 431

27 RECURRENT BRIEF DEPRESSION/ 50

28 SEASONAL AFFECTIVE DISORDER/ 1215

29 EMOTIONAL DISORDER/ 16028

30 MOOD DISORDER/ 37715

31 AFFECTIVE NEUROSIS/ 11525

32 BLUNTED AFFECT/ 646

33 MAJOR AFFECTIVE DISORDER/ 375

34 MINOR AFFECTIVE DISORDER/ 53

9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 35 421735 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34

36 cognitive therapy/ 42039

37 cognitive behavioral therapy/ 4591

38 CBT.mp. 12998

(cognitive adj3 therap$).mp. [mp=title, abstract, heading word, drug trade name, original 39 title, device manufacturer, drug manufacturer, device trade name, keyword, floating 53186 subheading word]

40 Psychotherapy/ 91457

41 psychotherap$.tw. 59510

42 psycho-therap$.tw. 287

43 36 or 37 or 38 or 39 or 40 or 41 or 42 153170

44 8 and 35 and 43 1784

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 156

Appendix B

Ovid Search Results # Search Statement Results

1 cognitive restructuring.mp. 753

2 cognitive strategy.mp. 316

((cognitive or cognition) adj3 (restructur$ or intervention$ or method$ or technique$ or 3 15510 modif$ or strateg$ or component$)).tw.

4 1 or 2 or 3 15518

5 Mood Disorders/ 12934

6 Affective Disorders, Psychotic/ 2197

7 Depressive Disorder/ 67564

8 Depression, Postpartum/ 4559

9 Depressive Disorder, Major/ 25423

10 Depressive Disorder, Treatment-Resistant/ 779

11 Dysthymic Disorder/ 1093

12 Seasonal Affective Disorder/ 1161

13 Neurotic Disorders/ 17930

14 DEPRESSION/ 99699

15 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 215796

16 CBT.mp. 8536

17 cognitive behavioral therapy/ 21341

18 (cognitive$ adj3 therap$).mp. 29697

19 Psychotherapy/ 51145

20 psychotherap$.tw. 37894

21 psycho-therap$.tw. 104

22 16 or 17 or 18 or 19 or 20 or 21 97037

23 4 and 15 and 22 778

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 157

Appendix C

PsycINFO Search Results # Search Statement Results

1 exp Cognitive Restructuring/ 726

2 cognitive restructur*.mp. 2460

3 Cognitive Intervention*.mp. 1434

4 exp Cognitive Techniques/ 15275

5 cognitive technique*.mp. 2027

6 Cognitive Strateg*.mp. 3089

7 cognitive modification*.mp. 142

8 cognitive component*.mp. 1948

((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique* or 9 30039 modif* or strateg* or component*)).tw.

10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 40970

11 exp Major Depression/ 116377

12 exp Anaclitic Depression/ 56

13 exp Dysthymic Disorder/ 1454

14 exp Endogenous Depression/ 1223

15 exp Postpartum Depression/ 4154

16 exp Reactive Depression/ 292

17 exp Recurrent Depression/ 746

18 exp Treatment Resistant Depression/ 1954

19 exp Atypical Depression/ 188

20 exp "Depression (Emotion)"/ 24113

21 exp Seasonal Affective Disorder/ 1021

22 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 140108

23 exp Cognitive Behavior Therapy/ 17971

24 CBT.mp. 11841

25 (cognitive adj3 therap$).mp. 38733 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 158

26 psychotherapy/ 47724

27 psychotherap$.tw. 103484

28 psycho-therap$.tw. 146

29 23 or 24 or 25 or 26 or 27 or 28 143427

30 10 and 22 and 29 3074

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 159

Linking Chapters three and four

In chapter three a scoping review was conducted that focused on core belief techniques used within CBT for the treatment of major depression. The review aimed to identify and describe treatment techniques targeting core beliefs, and to begin to identify and disseminate common treatment recommendations related to the identified techniques. The review uncovered two clusters of techniques: (1) techniques that identify core beliefs and (2) techniques that modify core beliefs. In addition, the review identified clinical recommendations that pertain to core belief techniques. Clinical recommendations pertained to the timing of the interventions, the application of a variety of techniques, focusing on central maladaptive and adaptive beliefs, and applying the techniques in the context of a strong therapeutic alliance. Future research ideas were suggested including the testing of the clinical recommendations.

In the next chapter, manuscript three will also examine core techniques in CBT for the treatment of major depression. The aim in manuscript three is however to conduct a systematic review including a meta-analysis of the studies that dismantled CBT into its components or techniques. The review will specifically examine cognitive techniques, and behaviour activation techniques, compared to combined cognitive-behavioural interventions, third wave techniques, and control conditions. The review will also examine the efficacy of these interventions as applied in individual therapy and in a group therapy setting.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 160

Chapter 4 – Therapist Techniques in Cognitive Behavioural Therapy for Reduction of

Depressive Symptomology: A Systematic Review of Cognitive Restructuring and

Behavioural Activation Techniques

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 161

Therapist Techniques in Cognitive Behavioural Therapy for Reduction of Depressive

Symptomology: A Systematic Review of Cognitive Restructuring and Behavioural Activation

Techniques

Amanda R. Sheptycki, Emma Schmelefske, Bassam Khoury, & Martin Drapeau

McGill University

Address Correspondence to Dr. Martin Drapeau, SAPP Lab-McGill, 3700 McTavish,

Montreal, Quebec, H3A 1Y2; email: [email protected]

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 162

Abstract

CBT is composed of therapist techniques that are often grouped into cognitive or behavioural activation interventions (Beck & Beck, 2011). These techniques have been compared and have demonstrated similar outcomes in the treatment of major depression, yet treatment recommendations prioritize treatment that incorporates full CBT. Systematic reviews have been conducted to compare second wave interventions in individual psychotherapy and less so in groups, focusing on a range of comparators outside the scope of CBT, and include heterogeneous groups such as older adults and postpartum depression. A meta-analysis is needed in order to focus on CBT strategies and related comparators (i.e., behaviour activation and third wave strategies) for a more select population (i.e., adults with major depression) that also examines delivery mode (individual and group psychotherapy). The current review aims to address this and will compare CBT therapeutic interventions and examine clinical significance of each intervention’s impact on depressive symptom change. The review examined three research questions: (1) Are cognitive restructuring techniques efficacious in reducing depressive symptomology when compared to a comparator?; (2) Are behavioural activation strategies efficacious in reducing depression symptoms when compared to a comparator?; (3) Are cognitive restructuring techniques and behavioural activation techniques efficacious in reducing depressive symptomology in group therapy when compared to a comparator? Results indicated that outcome associated with cognitive, behavioural, and cognitive-behavioural interventions did not significantly differ. Only few studies were available that compared individual interventions and third wave interventions. Research, and clinical implications are discussed.

Keywords: Cognitive interventions, behaviour activation, therapist techniques, major depression CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 163

Therapist Techniques in Cognitive Behavioural Therapy for Reduction of Depressive

Symptomology: A Systematic Review of Cognitive Restructuring and Behavioural

Activation Techniques

Cognitive Behavioural Therapy (CBT) has been described in numerous treatment manuals and researched for decades (e.g., Beck, 1963; Beck & Beck, 2011; Wenzel, 2017;

Wright, 2006). Therapeutic techniques are central to the approach and are often categorized into

(1) cognitive interventions and (2) behavioural activation interventions (Beck & Beck, 2011;

Kanter & Puspitasari, 2012; Leahy & Rego, 2012; Young, Weinberger, & Beck, 2001).

Cognitive interventions target distorted thought processes, and include strategies such as logical analysis, challenging automatic thoughts and Socratic questioning (Beck & Beck, 2011).

Behaviour activation strategies generally target adaptive and maladaptive behaviours (Kantor et al., 2010). Some examples of behaviour activation techniques include activity monitoring, assessment of life goals and values, activity scheduling, skills training, relaxation training, contingency management, procedures targeting verbal behaviour, and procedures targeting avoidance. Surprisingly, although CBT underlines the importance of using techniques such as behavioural activation and cognitive restructuring, relatively little research has examined how these techniques relate to treatment outcome in group and individual settings (Clark & Egan,

2015).

Cognitive Interventions and Behaviour Activation Interventions

Treatment manuals often suggest that specific cognitive techniques such as Socratic questioning, and behavioural activation strategies such as activity monitoring, are crucial strategies needed to treat depression (Clark & Egan, 2015; Kanter et al., 2010). Some research CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 164 suggests that the delivery of specific cognitive interventions or behaviour activation interventions may have an effect on reduction in depression symptoms. For example, Peterson,

Luborsky, and Seligman (1983) found that through the application of cognitive restructuring, patients demonstrated modifications in how they attribute negative events and that this was associated with reductions in depressive mood. In another study, Clore and Gaynor (2012) compared the efficacy of cognitive modification strategies to supportive therapy. The cognitive modification group was composed of both thought records to challenge negative thoughts and fluency training to enhance positive cognitions. The supportive therapy was focused on exploring emotions and developing awareness of the participant’s emotional experience. The authors found a significant difference between the two treatment conditions: the participants in the cognitive modification condition were reported to have larger changes in levels of internalizing distress and positive thinking. Similarly, specific behavioural activation strategies have been examined in the literature. For instance, Burns and Nolen-Hoeksema (1992) found that patient completion of homework assignments was related to improved outcome. They further suggested that completing homework assignments may decrease depression symptoms by teaching the patient a way to cope with distorted thoughts and maladaptive behaviours. Many additional studies have examined individual cognitive (Braun, Strunk, Sasso, & Cooper, 2015;

Jarrett & Nelson 1987; Persons & Burns, 1985; Teasdale & Fennell, 1982) and behavioural activation strategies (Ekers et al., 2008; Maldonado Lopez, 1982 Neimeyer, Kazantzis, Kassler,

Baker & Fletcher, 2008).

These studies provide some preliminary evidence for the importance of individual techniques and combinations of CBT techniques. A review is however needed to begin to systematically identify the results of these studies or call attention to the need for additional CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 165 studies in order to guide clinical resources such as treatment manuals. Such a review is also needed because previous meta-analyses, few in number, suggest that a full course of CBT may not be more efficient than using certain specific techniques (Cuijpers et al., 2013). Indeed, and while treatment guidelines often indicate that CBT is a first-line treatment for depression and behavioural activation is a secondary treatment approach (National Institute for Health and

Clinical Excellence [NICE], 2018), previous work suggests there is conflicting evidence to the effect that both cognitive interventions and behavioural interventions may not be needed in order to have the same impact on reducing major depression as a full course of CBT (Jacobson et al.,

1996). Congruent with this, Mazzucchelli and colleagues (2009) completed a meta-analysis comparing behavioural activation techniques to full CBT (full CBT refers to cognitive restructuring components and behaviour activation strategies). The behavioural activation treatment included interventions such as increasing pleasant activities, increasing self-control, and planning behavioural activities. Results indicated that behavioural activation interventions were equally efficacious as full CBT (this review however did not include a cognitive restructuring group for comparison). Other meta-analyses have compared behavior activation with cognitive work. In one such meta-analysis, Cuijpers and colleagues (2007) compared behaviour activation (composed primarily of activity scheduling) to cognitive therapeutic techniques and found no significant difference between the outcome of the two groups. A more recent review found similar results, concluding that there was no significant difference between behaviour activation and cognitive restructuring as both were equally efficacious in the treatment of major depression (Cuijpers et al., 2013). Bell and D’Zurilla (2009) completed a meta-analysis on problem solving therapy for depression. Problem solving therapy component was defined as including the four components of problem solving orientation, problem solving skills, training on CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 166 both components (i.e., problem solving orientation and problem solving skills), and assessing social problem solving skills. The comparators included alternative psychosocial therapy (see

Bell & D’Zurilla, 2009) and they did not include a comparator of other CBT strategies. Results indicated Problem Solving Therapy was equally effective as psychosocial therapy and significantly more effective than the control condition. Cuijpers, Andersson, Donker, and Van

Straten (2011) completed a large scale meta-analysis comparing the full treatment approaches to

CBT including interpersonal psychotherapy, psychodynamic psychotherapy, behaviour activation therapy, self-control therapy, and problem solving therapy. Cuijpers and colleagues included a range of treatment groups including, older adults, women with postpartum depression, patients in primary care, and inpatients. They found most therapies are equally effective and reported only small differences across psychotherapies. Cuijpers and colleagues reported limitations of the poor quality of many of the studies included.

Clearly, more research on this topic, especially in the form of systematic reviews and meta-analyses, are needed. Further studies on this topic, especially knowledge syntheses, are also needed because existing meta-analyses and reviews have included comparators such as interpersonal therapy, brief psychodynamic therapy, supportive counseling, and problem solving, but none included more recent third-wave strategies. Given the growth of third wave approaches such as mindfulness, it is highly warranted that a review includes third wave strategies (Hayes &

Hofmann, 2017). Finally, most reviews have focused on individual therapy. However, CBT is often delivered in a group setting and systematic reviews and meta-analyses of outcome studies are less prevalent for group delivered psychotherapy (Huntley, Araya & Salisbury, 2012;

Okumura & Ichikura, 2014). Conclusions drawn from studies on these individually delivered treatments are often used to inform group treatment, yet research suggests that the processes CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 167 involved in these two modes of delivery can be quite different (NICE, 2018). It is argued that in many settings group treatment is more cost-effective than individually delivered treatments

(Huntley, Araya & Salisbury, 2012). In a recent review Okumura and Ichikura (2014) called for additional high quality trials and reviews of group CBT interventions. Therefore, there appears to be a need to further explore how behaviour activation, cognitive interventions and the full approach of CBT impact treatment outcomes when delivered in groups, in addition to individually (Huntley, Araya & Salisbury, 2012).

The Present Review

Although CBT has been studied extensively, it remains unclear how techniques compare in the treatment of major depression. Conducting a systematic review and meta-analysis of the existing literature addressing these gaps, appears to be a truly necessary next step. This study aims specifically to review the relationship between different types of CBT interventions and techniques, and how they are related to changes in depressive symptomology. More specifically this review examined: (1) The efficacy of cognitive interventions in relation to comparator interventions (behavioural activation techniques, full cognitive-behavioural treatments, third wave cognitive techniques, and control conditions) in reducing symptoms of depression; (2) The efficacy of behavioural interventions compared to comparator interventions (full cognitive- behavioural treatments, third wave cognitive techniques, and control conditions) in reducing depressive symptoms; (3) The efficacy of group cognitive-behavioural (full CBT) interventions compared to comparator interventions (behavioural activation techniques, cognitive interventions, third wave cognitive techniques or control conditions) in reducing depressive symptoms.

Method CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 168

The systematic review followed the framework described by the National Institute for

Health and Clinical Excellence (National Institute for Health and Clinical Excellence, 2012), and the Cochrane Collaboration’s framework (Grimshaw, 2010). The steps included: (1) identifying research objectives and clearly stating the research question, (2) defining inclusion and exclusion criteria, (3) describing the search strategy, (4) identifying eligible studies, (5) appraising the quality of the studies, (6) extracting the data, and (7) data synthesis and reporting of the data.

The first step involved clearly stating the research objectives and questions. Three research questions were identified, and for each, the PICO framework (Higgins & Green, 2008) was used to define the Participants, Interventions, Comparison and Outcome.

(1) Are cognitive restructuring techniques efficacious in reducing depressive symptomology when compared to the comparator? The Participants included adult patients (18 to 64 years of age) who met criteria for major depression assessed through a validated measure or a structured interview. The Intervention included identifying and labeling cognitive errors, eliciting automatic thoughts, observing and recording automatic thoughts, distancing and decentering, thought records, identifying themes, thought counting and scaling, guided discovery, logical analysis, hypothesis testing, Socratic questioning, evaluating thoughts, exploring advantages and disadvantages, examining evidence, reality testing, reframing, reattribution, decatastrophizing, cognitive rehearsal, externalizing thoughts or voices, fantasizing consequences, generating and examining alternatives, identifying core beliefs, modifying beliefs, challenging core beliefs, downward arrow, exploring the advantages and disadvantages, developing alternative beliefs (Beck & Beck, 2011; Leahy & Rego, 2012). The intervention was not limited to a certain duration, or number of therapeutic sessions. Interventions were to be administered face-to-face and interventions delivered via telephone or computer were excluded. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 169

There was no limitation on the intervention setting. The Comparator included behaviour activation techniques, cognitive techniques from a third-wave approach, and combinations of cognitive and behavioural techniques. Third-wave approaches included interventions (e.g., mindfulness training, and cognitive defusion) from approaches such as Acceptance and

Commitment Therapy, Compassionate Mind Training, Functional Analytic Psychotherapy,

Metacognitive Therapy, Mindfulness-Based Cognitive Therapy, and Dialectical Behaviour

Therapy. Third wave approaches included were established based on criteria from previous

Cochrane reviews and through consultation with researchers with experience with third wave approaches and systematic reviews (Churchill et al., 2013; Shinohara et al., 2013). Records also needed to include a control group such as treatment as usual, wait-list control, or no-treatment control. Each comparison either focused on individual interventions (e.g., progressive muscle relaxation vs. mindfulness) or groups of interventions (e.g. cognitive restructuring interventions vs. behaviour activation interventions). Finally, Outcome was defined first (primary outcome) as depression symptomology measured by the Beck Depression Inventory-I (BDI-I; Beck, Rush,

Shaw, & Emery, 1979) and Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996).

A secondary outcome measure included recovery status following criteria established by Beck,

Steer, and Brown (1996). The BDI and recovery status were chosen as the BDI is commonly used to measure depression across studies, and both have been used as an outcome measures in past systematic reviews for the treatment of Major Depression.

(2) Are behavioural activation strategies efficacious in reducing depression symptoms when compared to the comparator? The Participants again included adult patients (18 years of age or older) who met criteria for major depression as defined above. The intervention included activity monitoring, assessment of goals and values, activity scheduling, skills training, CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 170 relaxation training, contingency management, procedures for targeting verbal behaviour, behavioural experiments, and procedures for targeting avoidance (Kanter & Puspitasari, 2012;

Manos, Kanter, & Busch, 2010). The Comparator included third-wave cognitive techniques and interventions combining cognitive and behavioural techniques. Criteria for comparators related to control group, individual and combined interventions were the same as in Question 1.

Outcome was defined as in Question 1.

(3) Are cognitive restructuring techniques and behavioural activation techniques combined (full CBT) efficacious in reducing depressive symptomology in group therapy when compared to the comparator? The Participants were the same as for Questions 1 and 2. The

Intervention included all cognitive and behavioural interventions outlined in Questions 1 and 2.

The Comparator included group behavioural activation, cognitive interventions and third wave cognitive interventions. Additional inclusion criteria for comparators are outlined in Questions 1 and 2. Outcome was defined as in Questions 1 and 2.

The second step entailed defining the inclusion and exclusion criteria to establish clear guidelines for records to be incorporated into the review. Two reviewers developed the criteria and consulted with a third reviewer for feedback or when disagreement occurred. Reviewers were doctoral students who have had previous training in conducting systematic reviews and meta-analyses, as well as previous clinical training in CBT and third-wave approaches. The inclusion and exclusion criteria were organized into 8 categories including: population type, disorder or medical condition, intervention type, orientation, discipline, study design, source and language. For the population criterion, records were included if they focused mainly on adults, as defined in the PICO, and were excluded if they focused on children, adolescents or older adults.

For the disorder or medical condition criterion, congruent with the pre-established PICO, records CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 171 were included if they were centered on patients treated primarily for major depression or related mood disorders such as treatment resistant depression, or persistent depressive disorder.

Comorbid conditions such as schizophrenia and other psychotic disorders, substance-related and addictive disorders, smoking cessation, trauma- and stressor-related disorders, dissociative disorders, feeding and eating disorders, sleep-wake disorders, sexual dysfunction disorders, conduct disorders, and personality disorders were excluded. The only comorbid condition that was included was the presence of symptoms of anxiety; however, records were excluded if the intervention specifically focused on treating a specific anxiety disorder. Studies that focused on treating specific medical conditions or that included patients with impairment in neural functioning were also excluded. For the intervention type criterion, as per our PICO, studies were included if they centered on cognitive, behavioral, and third-wave techniques; these also needed to be administered by mental health professionals (e.g., psychologists, social workers, marriage and family therapists,) or by masters or doctoral psychology students. For the orientation and discipline criteria, records were included if they included behavioural, cognitive- behavioural or third-wave theoretical approaches eligible for inclusion. For the study design and the source criteria, the review included randomized control trials and meta-analyses and excluded grey literature. Finally, for the language criterion, only records in English were included.

The third step consisted of describing the search strategy. The search strategy was developed in consultation with a librarian from McGill University experienced in conducting systematic reviews. The search string was based on evidence-based searches and was executed in three electronic databases – PsychINFO, Embase and Medline (between 1964 to 2019), and two clinical trial databases – ClinicalTrials.gov and UK Clinical Trials. Reference lists from meta- CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 172 analyses were also reviewed for additional records. The search was initially executed on May

28th, 2018 (electronic databases, n = 2975) clinical trials, n = 39); an updated search was completed on July 18th, 2019 (electronic databases, n = 345; clinical trials, n = 9) to incorporate additional more recent records (see Appendix A through C). The records were managed and saved using Endnote (version X8.0.1) on May 28th, 2018 (see Figure 1) and later updated on July

18th, 2019

In step four of the review, identifying eligible studies, two trained raters applied inclusion and exclusion criteria to the records retrieved. While a third rater was available for consultation.

All discrepancies were resolved through discussion between the two first raters. The selection of the studies was conducted in steps. First, duplicates were removed and records were examined at the abstract level (search 1, n = 2152; search 2, n = 294; see Figure 1) using Rayyan QCRI. From these records, a select number (search 1, n = 92; search 2, n = 6) were then reviewed at the full- text level for inclusion. A total of 10 records (search 1, n = 9, search 2, n = 1) were finally included within the review. A flow chart diagram was incorporated, detailing records at each stage of the screening process following PRISMA guidelines (Moher, Liberati, Tetzlaff, &

Altman, 2009) for the original search and for the updated search (see Figure 1).

The fifth step consisted of assessing the quality of the included studies (n = 10). The risk of bias within studies was assessed following the widely used Cochrane Collaboration framework (Higgins & Altman, 2008). This systematic approach to making judgments on the quality of studies assists in reducing or preventing errors, fosters a careful review of the study, and helps provide a way of systematically communicating the quality of studies within the review. Three reviewers were involved in appraising records (see Table 1). CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 173

The sixth step of the review, data extraction, was completed by the three reviewers on selected records and maintained in an Excel spreadsheet. Reviewers completed training on data extraction and consultations were regularly conducted in order to ensure reliability across raters.

The reviewers extracted relevant information such as publication type, patient diagnosis, interventions included, comparators, treatment type, duration, number of sessions, training level of clinicians, and demographics (see Table 2). Data from each record regarding effect size related to reduction in depressive symptomology was extracted.

The seventh and final step involved synthesizing, completing statistical analyses, and reporting the data.

Statistical Analyses

Summary measures. The analyses were conducted using Comprehensive Meta-

Analysis, Version 2 (CMA; Borenstein, Hedges, Higgins, & Rothstein, 2005). The analyses used pre-test and post-test data for depressive symptomology from each record.

Synthesis of results. Effect sizes were computed within CMA through the use of means and standard deviations as each record reported these statistics. Effect sizes were computed using

Hedge’s g and a random effects model, as these tend to be more conservative and more accurate with studies that vary in sample size. Hedge’s g was computed for each comparison group using a 95% confidence interval. Standard errors, z-values and p-values were also reported.

Heterogeneity was calculated for each comparison and associated Q, I2 and Tau2 were reported.

Results were interpreted using Higgins, Thompson, Deeks, and Altman’s (2003) criteria for I2, where 25% was considered low, 50% was considered moderate, and 75% was considered high.

Primary outcome: Intervention comparator analyses. Analyses were conducted related to each research question. Hedge’s g was computed for each comparison, including CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 174 cognitive interventions versus the comparator (control, cognitive-behavioural, and behavioural) and behavioural interventions versus the comparator (control, cognitive-behavioural, and third- wave).

Secondary outcome: Clinical significance. Secondary outcome analyses were calculated to determine important clinical implications (e.g., change in clinical level of depression) related to each research question. Recovery status and rating (as secondary outcome) was determined for each group for pre- and post- weighted means. Levels of depression were considered to be minimal if scores on the BDI fell between 0 to 13, mild if they fell between 14 to 19, and moderate if they fell between 20 to 28, and severe if they fell between 29 to 63 (Beck,

Steer, & Brown, 1996). Criteria for recovery were met when the BDI was less than 9 points.

Bias across studies. Analyses were conducted to assess for risk of bias across studies.

The fail-safe N was computed and a funnel plot was created.

Bias within studies. A risk of bias within studies was assessed for each record. Studies were assessed based on the six categories outlined in the Cochrane framework (Higgins &

Altman, 2008): selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias. Within each category, records were ranked and recorded in a summary of finding table (see Table 1). Two reviewers completed independent ratings of each record and met for consultations in order to obtain final ratings. Discrepancies were discussed and a third rater was available in the case of disagreement.

Results

A total of 10 records (search 1, n = 9, search 2, n = 1) were included within the review.

Study Characteristics CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 175

All 10 of the studies were random control trials and used a between-subjects design. The control conditions included in these studies consisted of four wait list controls, two treatments as usual, one no treatment control, and three standard support treatments. Within the 10 studies, there were four cognitive treatment groups, seven behavioural treatment groups, three cognitive- behavioural interventions, and two third-wave (mindfulness) treatment groups. There were two studies that included a treatment group focusing on individual behavioural activation strategies such as progressive muscle relaxation. Eight of the included studies provided individual psychotherapy and two of the studies delivered group psychotherapy.

Each study included pre- and post- data for symptoms of depression. The outcome measure common to all 10 studies was the BDI. Additional outcome measures included in some of the studies were the Hamilton Rating Scale for Depression (Miller et al., 1985), Modified Scale for

Suicidal Ideation (MSSI; Miller, Norman, Bishop & Dow, 1986), Symptom Checklist 90 (SCL-

90; Derogatis & Unger, 2010), and Beck Anxiety Inventory (BAI; Beck & Steer, 1993)

Effects Grouped by Question

Primary and secondary outcomes are presented for each question. Primary outcomes report on each intervention comparator analysis when sufficient records were obtained to conduct a meta-analysis (e.g., two or more records). Secondary measures report on clinical significance; the weighted mean scores on the BDI or BDI-II at pre- and post-treatment for each comparator. Three comparisons were completed for question one, and three comparisons were completed for question two. Given the limited number of records found for question three, pertaining to group therapy, only secondary outcome measures were computed and will be reported. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 176

Six comparisons will be discussed related to the initial research questions. Comparisons pertain to research question one (comparisons one through three) and two (comparisons four through six) and each comparison includes treatments applied in individual therapy. Given the limited number of group psychotherapy records identified, results were reported based on secondary outcome measure of recovery status presented in clinical significance.

Question 1: Primary outcome measure. Three comparisons were completed including cognitive interventions versus controls, cognitive interventions versus cognitive-behavioural interventions, and cognitive interventions versus behavioural interventions. Cognitive interventions compared to third-wave interventions will not be reported related to lack of available records.

Comparison 1: Cognitive interventions versus controls. This comparison included three studies (McNamera & Horan, 1986; Taylor & Marshall, 1977; Wilson, Goldin & Charbonneau-

Powis, 1983) and 51 patients. Each study was conducted in university psychology clinics.

Therapy was delivered by Ph.D. students in two studies and Ph.D. level psychologists in one study. Control interventions included two wait list control conditions and a standard support control, which was defined as a group composed of non-directive discussions. Depressive symptoms were measured with the BDI for each study. One study (Taylor & Marshall, 1977) additionally applied the D-30 scale (Dempsey 1964), and another (McNamera & Horan, 1986) also incorporated the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960).

A significant effect was found when comparing cognitive interventions with controls (see

Table 3), Hedge’s g = 1.41 (95% CI [.24, 2.58], p < .05). Variation in effect size related to heterogeneity was substantial (I2 = 72.48%, Q = 7.27). Publication bias was calculated and effect sizes for pre- and post- data on depressive symptoms from the studies corresponded to a z-value CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 177 of 4.40 (p < .001), meaning that a minimum of 13 studies with null results would be required to nullify the results obtained in the present review. The Trim and Fill method indicated that two studies to the left of the mean would be needed to make the funnel plot symmetrical, resulting in an adjusted effect size of Hedge’s g = .46 (see Figure 2). The adjusted effect size is low-to- moderate, compared to the large effect size (i.e., Hedge’s g = 1.41) found in the observed studies.

This indicates that the effect size may be over-estimated due to publication bias.

Comparison 2: Cognitive interventions versus cognitive-behavioural interventions (full

CBT). This comparison included two studies and 34 patients. Both studies were conducted in university counseling clinic settings. In one study, therapy was conducted by Ph.D. and master’s students, while in the other it was conducted by psychologists. Control interventions within the studies included wait-list control and a standard support control, which was defined in Question

1. Depressive symptoms were assessed at pre-test using the BDI, the D-30 Scale (Dempsey,

1964) and the HRSD (Hamilton, 1960). The BDI was administered to determine depression ratings at termination.

Overall, a non-significant effect was found when comparing cognitive interventions to full cognitive-behavioural interventions (see Table 4), Hedge’s g = -.42 (95% CI [-.1.79, .96], p

= ns). Variation in effect size showed high heterogeneity (I2 = 75.46%, Q = 4.08). Given the low number of studies, a precision analysis was not feasible.

Comparison 3: Cognitive interventions versus behavioural interventions. Consistent with the first comparison, this comparison included three studies and 51 patients. Studies were conducted in university counseling centers and therapists consisted of master’s students, Ph.D. students, and psychologists. Pre-test and post-test measures for all studies used the BDI. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 178

Overall a non-significant effect was found when comparing cognitive interventions to behavioural interventions, Hedge’s g = -.07 (95% CI [-.86, .72], p = ns), with moderate heterogeneity (I2 = 53.38%, Q = 4.29).

Question 1: Secondary outcome measure. Interventions included in question 1 were also examined for effect on recovery status computed through weighted means (see Table 9).

Additional interventions pertaining more specifically to question 2 will be presented in the following section (i.e., behavioural activation). In the cognitive intervention groups, participants scored in the moderate range on the BDI at pre-test (M = 24.24); however, scores decreased to the recovery range at post-test (M = 8.36). Similarly, in the cognitive-behavioural interventions, participant scores fell from the moderate range (M = 21.24) to the recovery range (M = 5.13). In the behavioural intervention groups (n = 6) scores declined from moderate to minimal from pre- to post-testing. The four control conditions grouped together showed a less substantial decrease in depression, with pre-test scores averaging in the moderate range (M = 22.60) and post-test scores averaging in the mild range (M = 15.90).

Question 2: Primary outcome measure. Three comparisons were completed including behavioural interventions versus controls, behavioural interventions versus cognitive-behavioural interventions, and behavioural interventions (Progressive Muscle Relaxation) versus third-wave interventions (Mindfulness).

Comparison 4: Behavioural interventions versus controls. This comparison included three studies and 61 patients. Studies were primarily conducted in university counseling centers and one was conducted in a state psychiatric facility. In most studies, therapy was conducted by graduate students at the master’s and Ph.D. level and in one study the therapy was conducted by clinical psychologists. Control interventions within the studies specifically included wait list (n = CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 179

2), and no-treatment control (n =1). Depressive symptoms were assessed using either the BDI, the D-30 Scale, the Diagnostic Interview Schedule, or the ICD-10.

Overall, a positive significant effect was found when comparing behavioural interventions to control groups, favouring behavioural interventions (see Table 6), Hedge’s g =

1.89 (95% CI [1,30, 2.48], p < .001), with moderate heterogeneity (I2 = 0%, Q = .56). Given the number of included studies, risk of bias across studies was computed on pre- and post-data, with a z-value of 6.30 (p < .001). Given the low number of studies, a precision analysis was not feasible.

Comparison 5: Behavioural interventions versus cognitive-behavioural interventions (full

CBT). Consistent with Comparison two, this comparison included two studies and 34 patients.

Depressive symptoms were assessed at pre- and post-testing with the BDI (see Table 7). Overall effects were not significant, Hedge’s g = .15 (95% CI [-.1.23, .1.53], p = ns), with high heterogeneity (I2 = 76.75%, Q = 4.30).

Comparison 6: Behavioural Activation (Progressive Muscle Relaxation) versus Third- wave Interventions (Mindfulness). This comparison included two studies and 144 patients.

Studies were conducted in university counseling clinic settings. Progressive Muscle Relaxation

(PMR) included guided training on PMR Mindfulness interventions included elements of mindfulness training from MBCT. Therapy was conducted by Ph.D. students in one study

(McIndoo, File, Preddy & Hopko, 2016) and clinical psychologists in the second study (Mander et al., 2019). Control interventions specifically included treatment as usual and wait-list control.

Depressive symptoms were assessed using the BDI (Beck, Steer, & Brown, 1996). Additional measures were also used in these studies including the Brief Symptom Inventory (BSI; Derogatis

& Melisaratos, 1983; Franke, 2000), the Working Alliance InventoryShort Revised (WAI CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 180

SR; Hatcher & Gillaspy, 2006), the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, &

Steer, 1988), the Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith, & Allen, 2004), the Hamilton Rating Scale for Depression (HAMD; Hamilton, 1967), and the Hamilton Rating

Scale for Anxiety (HAMA; Hamilton, 1959). No difference in effect size was found between behavioural activation interventions and third-wave mindfulness interventions (see Table 8),

Hedge’s g = -.02 (95% CI [-.34, .31], p = ns), and heterogeneity was low (I2 = .0%, Q = .01).

Question 2: Secondary outcome measure. Interventions included in question two were also examined for clinical significance as computed through weighted means (see Table 9). In the behavioural intervention groups (n = 6) scores declined from moderate to minimal from pre- to post-testing. The behavioural interventions of Progressive Muscle Relaxation (PMR) did not demonstrate a change in depression range. On the other hand, the weighted mean BDI score for patients who received mindfulness interventions went from pre-test scores within the severe range (M = 29.12) to post-test scores within the mild range (M = 18.25).

Question 3: Primary and secondary outcome measure. Given the limited number of group psychotherapy records identified, results were reported based on secondary outcome measure of recovery status only. Weighted means were calculated for group treatments for the comparators of cognitive-behavioural interventions, cognitive interventions, behavioural interventions and control groups (see Table 10). The patients in the cognitive intervention demonstrated the greatest change from severe at pre-test (M = 30.10) to minimal at post-test (M = 9.90). For the cognitive-behavioural intervention the participants presented at pre-test with mild depression (M

= 15.78) and at post-test with minimal depression (M = 9.64). For the behavioural intervention, which included one study, the participants had ratings of moderate (M =25.6) at pre-test and mild CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 181

(M = 18) at post-test. Finally, the control condition remained within the mild ranges at pre- and post-testing.

Risk of Bias within Studies

The Cochrane Collaboration’s framework was applied to assess risk of bias (Higgins et al., 2011). Selection bias was assessed for random sequencing and allocation sequencing (see

Table 1). The risk of bias for random sequencing was unclear for the majority of studies (70%), low for three studies and high for one study. For allocation sequencing, the majority of studies

(70%) did not conceal allocation and three studies included detailed information on the concealment process. Risk of performance bias was high for all studies as blinding of participants and personnel was not discussed in any of the studies. Furthermore, blinding of personnel is nearly impossible in psychotherapy trials, given that treatment necessitates the therapist knowing which form of therapy they are delivering. Risk of detection bias was high in the majority of studies (60%) as blinding of outcome assessments was not clearly discussed in most studies. Risk of attrition bias was assessed and half of the studies were at low risk of bias as attrition rates were low and tended to be balanced among groups. For the remaining studies, the bias was unclear as this information tended not to be reported. Risk of reporting bias tended to be unclear (80%) and was high for one study (Ekers et al., 2011) as service utilization data was mentioned as outcome in protocol but was not reported in the paper. No additional risk of bias was apparent.

Discussion

An analysis was conducted in order to compare the efficacy of cognitive interventions, behavioral activation, and cognitive-behavioral interventions in reducing the symptoms of depression. The review included 10 studies meeting criteria for inclusion. These records allowed CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 182 for various comparisons that included (1) cognitive interventions compared to behavioural activation, cognitive-behavioural interventions and controls, (2) behavioural activation compared to cognitive-behavioural, and controls, and (3) individual behavioural interventions compared to third wave mindfulness interventions.

First, when compared to control conditions, both the cognitive interventions and the behavioural activation interventions were associated with a significant decrease in symptoms of depression. Overall, these results indicate that both central interventions of CBT have a significant impact on patient outcome when it comes to decreasing symptoms of depression.

Second, when comparing cognitive interventions, behavioral activation interventions, and cognitive-behavioral interventions to each other, results show that all three groups do not significantly differ in terms of patient outcome. This suggests that all three types of intervention are somewhat equivalent in their ability to decrease symptoms of depression. When behavioural interventions were compared to third-wave mindfulness interventions, results further demonstrated no difference across these two active conditions. These results may indicate the similar effects of behavioural, second-wave cognitive, cognitive behavioural and third-wave interventions on depressive symptoms. Additional analyses would need to be conducted prior to drawing any conclusions.

The changes in specific depression scores from pre-intervention to post-intervention were also closely examined for each type of intervention (cognitive, behavioral activation, cognitive- behavioral and third-wave mindfulness) given in both individual or group therapy. Weighted means were used in order to obtain meaningful comparisons between pre- and post- interventions. Cognitive interventions and cognitive-behavioural interventions delivered in individual therapy were shown to reduce depression to the point where recovery criteria were CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 183 met. This suggests that in addition to being efficacious when compared to controls, these techniques are also clinically efficacious, given that both techniques seem to have produced clinically meaningful reductions in depression as measured by the BDI. Three conditions achieved a post-test rating of minimal depression: behavioural activation delivered in an individual context, and cognitive-behavioural and cognitive interventions in group contexts. Two active intervention groups attained mild levels of depression at post-treatment; these included individually-delivered mindfulness, and group-delivered behavioural interventions. This suggests that both individual and group treatment formats can lead to clinically meaningful changes in depression. Most intervention groups at pre-test had ratings of moderate depression, including individually delivered interventions of cognitive, cognitive-behavioural, behavioral, progressive muscle relaxation, and group delivery of behavioural interventions, while weighted means for mindfulness and cognitive interventions in a group setting were categorized as severe for depression symptomology at pre-test.

The review had a number of strengths and limitations. The study is one of the first to compare groups and individual interventions that included second- and third-wave approaches.

Further, the study included a separate examination of interventions applied in a group context.

The study also provides support for the similar impact of different groups of interventions such as behavioural, cognitive, and cognitive-behavioural. Despite this, limitations must also be highlighted. Firstly, the number of studies included was limited, which restricted the number of comparisons that could be made. There were not enough records to compute comparisons for group-delivered interventions and group interventions could only be examined through weighted means. Secondly, there were limited studies that compared individual cognitive or behavioural interventions, and this limited our ability to determine the efficacy of individual interventions. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 184

Thirdly, including only randomized control trials limited the analyses. Some studies identified in the literature search included relevant experimental groups; however, those studies had to be excluded because they did not include a control condition. Fourthly, there were concerns related to heterogeneity or high variation across studies. Some of the comparisons were found to have an elevated risk of heterogeneity. It appears this was related to the small number of studies, and number of overall participants. There are also concerns related to generalizability of the study results, given that only randomized control trials were included targeting major depression. For instance the studies included were not representative of the often comorbid conditions (e.g., anxiety disorders and substance use disorders) that are commonly observed in clinical settings

(Swendsen & Merikangas, 2000). Lastly, Major Depressive Disorder and related mood disorders such as treatment-resistant depression and dysthymia were included. Although, many comorbid disorders were excluded, these related mood disorders also vary considerably and criteria could be more specific to major depression in future studies.

Despite these limitations, this review meaningfully contributes to the body of literature assessing treatment outcome of CBT techniques, leading to a number of important clinical implications. Results of this study show that cognitive, behavioral, and cognitive-behavioural interventions have similar impacts on depression. It appears that the combination or more individualized interventions (e.g., behavioural activation only or cognitive restructuring only) are indicated for the treatment of depression, and that the combination of behavioural activation and cognitive restructuring does not result in significantly improved outcomes. This may indicate that clinicians have more interventions at their disposal when each is equally effective.

Additionally, given that these interventions produce comparable results, it may be important to consider other factors when training clinicians such as cost-effectiveness and complexity of CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 185 interventions. Behavioural activation interventions have been noted to be more cost-effective and are more straightforward for training new clinicians (Jacobson & Gortner, 2000; Robinson,

Wischman, & DelVento, 1996). Jacobson and colleagues component analysis further supported this as behavioural activation components were found to be as efficacious as the full approach.

Although further studies would be needed in order to draw conclusions, third wave individual interventions, such as mindfulness, appear to not significantly differ from individual behavioural activation interventions such as progressive muscle relaxation. Lastly, although manuals often describe interventions such as Socratic Questioning (Carey & Mullan, 2004) and activity scheduling (Kanter et al., 2012) as cornerstone interventions, there is a lack of empirical evidence for these interventions and it appears further research is needed in order to determine whether these interventions are integral to the approach. Future research would benefit from exploring these techniques efficacy in reducing major depression.

Through the completion of this meta-analysis, it is apparent there are several related research areas that would benefit from further exploration. Future research could examine moderating variables (e.g., gender, and treatment setting) or individual techniques that are identified as key to each cluster of interventions in order to determine their effectiveness rather than focusing on groups of interventions. Further, it appears there is still a need for individual studies to explore third-wave interventions effect on depressive symptomology. Although several key search terms during the literature review were included to identify a multitude of third-wave techniques, the studies mainly identified mindfulness interventions. In order to work through the current lack of studies, future meta-analyses that include non-randomized control trials in their review may lead to a greater number of records. Additionally, a future meta-analysis focusing primarily on group interventions for depression may be beneficial to explore a larger range of CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 186 intervention types such as interpersonal therapy, and the advantages of combinations of second- and third-wave interventions in a group context. Future research addressing the limitations of the present review, further examining individual interventions, and comparing interventions to additional third-wave interventions, is highly recommended.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 187

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Table 1.

Quality Assessment of Included Studies

Study Random Allocation Blinding of Blinding of Incomplete Selective Other Bias Sequence Concealment Participants Outcome Outcome Reporting Generation (Selection and Personnel Assessment Data (Reporting (Selection Bias) (Performance (Detection (Attrition Bias) Bias) Bias) Bias) Bias)

Allart-van Dam et al. Unclear High High Low Unclear Unclear Low (2003)

Ekers et al. (2011) Low Low High Low Low High Low

Gawrysiak et al. Unclear High High High Low Unclear Low (2009)

Hopko et al. (2003) Unclear High High High Unclear Unclear Low

Mander et al. ( 2019) Low Low High High Low Low Low

McIndoo et al. Low Low High High Low Unclear Low (2016) McNamara & Horan Unclear High High High Low Unclear Low (1986)

Shaw (1977) Unclear High High High Unclear Unclear Low CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 197

Taylor et al. (1977) Unclear High High Low Unclear Unclear Low

Wilson et al. (1983) High High High Low Unclear Unclear Low

Note. Ratings: high, the risk of bias in this domain is high; low, the risk of bias in this domain is low; unclear, the risk of

bias in this domain is unclear .

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 198

Table 2.

Characteristics of individual study designs

Study Interventions Control Duration of Number of Training Type Age Gender Ethnicity Follow-up Patient Group Treatment Sessions Level of (mean Diagnosis Clinicians and range)

Allart-van Cognitive Standard 2 hours/week, 12 Ph.D. Group 45.5 62% female Not specified 12 month Depressive Dam et al. behavioural support 12 weeks sessions students follow-up symptoms (2003) treatment Ekers et al. Behavioural TAU 1 hour/week 12 Mental Individual 46.43 65% female Not specified 3-month Depression (2011) activation for 3 months sessions health nurses follow-up

Gawrysiak et Behavioural No-treatment 90 min, once 1 session Ph.D. Individual 18.4 80% female 70% caucasian, None Depression al. (2009) activation control Students 13% african american Hopko et al. Behavioural Standard 20 min/week, 6 sessions Masters level Individual 30.5 36% female 96% caucasian, None Major (2003) activation support 2 weeks (or therapist 4% african Depression treatment until american discharge) Mander et al. Behavioural TAU 50 mins 25 Master's Individual 35.1 60% female Not specified None Major (2019) activation sessions for 25 sessions level Depression, (PMR), Third weeks psychologist Anxiety wave and graduate Disorder intervention students (Mindfulness) McIndoo et al. Behavioural Wait list 1 hour/week 4 sessions Ph.D. Individual 19 62% female 76% caucasian 1 month Depression (2016) activation, control for 4 weeks students follow-up and Mindfulness comorbid anxiety CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 199

McNamara & Cognitive, Standard 50 min/week 8-10 Doctoral Individual 23 (19- 73% female Not specified 2 month Major Horan (1986) Cognitive support for 10 weeks session interns and 31) follow-up Depression behavioural, treatment MA students Behavioural activation

Shaw (1977) Cognitive, Non-directive 2 hours/week 8 sessions Ph.D. Group 20 (17- 50% female Not specified 1 month Depression Behavioural group, wait for 4 weeks students 26) follow-up activation list control

Taylor et al. Cognitive, Wait list 40 mins for 6 6 sessions Graduate Individual 22.5 71% female Not specified 5 weeks MDD (1977) Cognitive control weeks Student behavioural, Behavioural activation

Wilson et al. Cognitive, Wait list 1 hour/week 8 sessions Psychologist Individual 39.5 80% female Not specified 5 months MDD (1983) Behavioural control for 8 weeks (20-58) activation

Note. TAU, treatment as usual; MDD, Major Depressive Disorder; PMR, Progressive Muscle Relaxation

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 200

Table 3.

Cognitive Interventions versus Control

Cognitive Control Confidence Heterogeneity Interval

Study n Pre Post n Pre Post Hedge’s SE Variance Lower Upper z-value p-value Q- I2 Tau2 Mean Mean Mean Mean g Limit Limit value (S.D.) (S.D.) (S.D.) (S.D.)

McNamara & 10 24.80 6.50 10 25.55 9.67 .46 .44 .19 -.39 1.31 1.06 .29 Horan (1986) (5.29) (4.17) (8.35) (5.75)

Taylor et al. 7 20.00 10.30 7 22.60 20.10 1.50 .58 .33 .37 2.63 2.61 .01** (1977) (4.90) (2.60) (5.10) (5.80)

Wilson et al. 8 27.25 9.00 9 23.66 21.44 2.47 .63 .39 1.24 3.70 3.94 .00*** (1983) (3.80) (6.82) (7.45) (5.52)

Test for 7.27 72.48 .77 heterogeneity

Test for 1.41 .60 .36 .24 2.58 2.37 .02* overall effects

*p < .05, ** p < .01, *** p < .001

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 201

Table 4.

Cognitive Interventions versus Cognitive-behavioural Interventions

Cognitive Cognitive-behavioural Confidence Heterogeneity Interval

Study n Pre Post n Pre Post Hedge’s SE Variance Lower Upper z-value p-value Q- I2 Tau2 Mean Mean Mean Mean g Limit Limit value (S.D.) (S.D.) (S.D.) (S.D.)

McNamara & 10 24.80 6.50 10 22.11 4.80 .25 .43 .19 -.60 1.09 .57 .57 Horan (1986) (5.29) (4.17) (4.28) (3.55)

Taylor et al. 7 20.00 10.30 7 20.00 5.60 -1.16 .55 .30 -2.23 -.09 -2.12 .03 (1977) (4.90) (2.60) (6.00) (4.70)

Test for 4.08 75.46 .74 heterogeneity

Test for -.42 .70 .49 -1.79 .96 -.59 .55 overall effects

*p < .05, ** p < .01, *** p < .001

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 202

Table 5.

Cognitive Interventions versus Behavioural interventions

Cognitive Behavioural Confidence Heterogeneity Interval

Study n Pre Post n Pre Post Hedge’s SE Variance Lower Upper z-value p-value Q- I2 Tau2 Mean Mean Mean Mean g Limit Limit value (S.D.) (S.D.) (S.D.) (S.D.)

McNamara & 10 24.80 6.50 10 25.90 5.50 -.52 .44 .19 -1.37 .34 -1.19 .23 Horan (1986) (5.29) (4.17) (4.04) (3.56)

Taylor et al. 7 20.00 10.30 7 22.10 10.70 -.40 .51 .26 -1.39 .59 -.79 .43 (1977) (4.90) (2.60) (5.90) (5.00)

Wilson et al. 8 27.25 9.00 8 21.13 7.50 .75 .49 .24 -.21 1.72 1.53 .13 (1983) (3.80) (6.82) (7.62) (4.55)

Test for 4.29 53.38 .26 heterogeneity

Test for -.07 .40 .16 -.86 .72 -.17 .87 overall effects

*p < .05, ** p < .01, *** p < .001

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 203

Table 6.

Behavioural Interventions versus Control

Behavioural Control Confidence Heterogeneity Interval

Study n Pre Post n Pre Post Hedge’s SE Variance Lower Upper z-value p-value Q-value I2 Tau2 Mean Mean Mean Mean g Limit Limit (S.D.) (S.D.) (S.D.) (S.D.)

Gawrysiak et 14 21.00 8.10 16 19.80 14.70 1.96 .44 .19 1.10 2.81 4.48 .00*** al. (2009) (6.60) (3.00) (4.70) (4.50)

Taylor et al. 7 22.10 10.70 7 22.60 20.10 1.54 .58 .34 .40 2.67 2.66 0.01** (1977) (5.90) (5.00) (5.10) (5.80)

Wilson et al. 8 21.13 7.50 9 23.66 21.44 2.13 .59 .35 .98 3.28 3.62 .00*** (1983) (7.62) (4.55) (7.45) (5.52)

Test for .56 .00 .00 heterogeneity CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 204

Test for 1.89 .30 .09 1.30 2.48 6.30 0*** overall effects

*p < .05, ** p < .01, *** p < .001

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 205

Table 7.

Behavioural Interventions versus Cognitive-behavioural Intervention

Behavioural Cognitive-behavioural Confidence Heterogeneity Interval

Study n Pre Post n Pre Post Hedge’s SE Variance Lower Upper z-value p-value Q- I2 Tau2 Mean Mean Mean Mean g Limit Limit value (S.D.) (S.D.) (S.D.) (S.D.)

McNamara & 10 25.90 5.50 10 22.11 4.80 .83 .45 .20 -.05 1.71 1.86 .06 Horan (1986) (4.04) (3.56) (4.28) (3.55)

Taylor et al. 7 22.10 10.70 7 20.00 5.60 -.58 .51 .26 -1.58 .43 -1.13 .26 (1977) (5.90) (5.00) (6.00) (4.70)

Test for 4.30 76.75 .76 heterogeneity

Test for .15 .71 .50 -1.23 1.53 .21 .83 overall effects

*p < .05, ** p < .01, *** p < .001

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 206

Table 8.

Behavioural Intervention versus Third-wave Intervention

PMR Mindfulness Confidence Heterogeneity Interval

Study n Pre Mean Post Mean n Pre Mean Post Mean Hedge’s SE Variance Lower Upper z- p- Q- I2 Tau2 (S.D.) (S.D.) (S.D.) (S.D.) g Limit Limit value value value

Mander et al. 54 24.17(12.27) 14.50(11.82) 54.00 28.91(9.49) 18.90(12.42) -.03 .19 .04 -.40 .35 -.15 .88 (2019)

McIndoo et 16 27.21(7.17) 13.93(10.15) 20.00 29.67(9.81) 16.50(12.80) .01 .33 .11 -.63 .65 .03 .98 al. (2016)

Test for .01 .00 .00 heterogeneity

Test for -.02 .17 .03 -.34 .31 -.11 .91 overall effects

*p < .05, ** p < .01, *** p < .001; PMR, Progressive Muscle Relaxation

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 207

Table 9.

Clinical Significance of Interventions Delive red Individual Psychotherapy

Pre Post

Condition No. of studies n Weighted Mean Severity n Weighted Mean Severity

Cognitive 3 25 24.24 Moderate 25 8.36 Recovery

Control 4 34 22.60 Moderate 34 15.90 Mild

Cognitive Behavioural 2 17 21.24 Moderate 17 5.13 Recovery

Behavioural 6 72 28.41 Moderate 72 10.68 Minimal

PMR 2 70 24.86 Moderate 70 24.84 Moderate

Mindfulness 2 74 29.12 Severe 74 18.25 Mild

Note. PMR, Progressive Muscle Relaxation; Recovery, 9 or less; Minimal, 0 to 13; Mild, 14 to 19; Moderate, 20 to 28; Severe, 29 to 63

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 208

Table 10.

Clinical Significance of Interventions Delivered in Group Psychotherapy

Pre Post

Condition No. of n Weighted Mean Severity n Weighted Severity studies Mean Cognitive Behavioural 1 61 15.78 Mild 61 9.64 Minimal

Cognitive 1 8 30.10 Severe 8 9.90 Minimal

Behavioural 1 8 25.60 Moderate 8 18.00 Mild

Control 2 49 16.06 Mild 49 15.90 Mild

Note. Recovery, 9 or less; Minimal, 0 to 13; Mild, 14 to 19; Moderate, 20 to 28; Severe, 29 to 63

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 209

th th Original search on May 28 , 2018 / Updated search on July 18 , 2019

Records identified through Additional records identified ation database searching through other sources (n = 2975 / n = 345) (n = 39 / n = 9) Clin Trials.gouv

Identific

Records after duplicates removed (n = 2152 / n = 294)

Screening Records screened Records excluded (n = 2152 / n = 294) (n = 2060 / n = 288)

Full-text articles Full-text articles assessed for eligibility excluded, with reasons (n = 92 / n = 6) (n = 83 / n = 5) Intervention-related = 39

Eligibility Study design = 36 Disorder or medical condition = 5 Studies included in qualitative synthesis Child or adolescent (n = 9 / n = 1) populations = 3 Language = 3

Grey literature = 2

Studies included in quantitative synthesis

Included (meta-analysis)

(n = 9 / n = 1)

Figure 1. PRISMA3 Flow Diagram. This figure shows the flow chart of the review (Moher et al.,

2009).

3 PRISMA stands for Preferred Reporting Items for Systematic reviews and Meta-Analyses. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 210

Funnel Plot of Precision by Hedges's g 3

2

1 Precision (1/Std Err)

0

-3 -2 -1 0 1 2 3

Hedges's g

Figure 2. Funnel Plot of Cognitive Interventions versus Control (CMA; Borenstein et al., 2005).

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 211

Appendix A

Embase Original Search

# Search Statement Results

1 cognitive therapy/ 42437

2 cognitive behavioral therapy/ 5329

3 CBT.mp. 13415

(cognitive adj3 therap$).mp. [mp=title, abstract, heading word, drug trade name, original 4 title, device manufacturer, drug manufacturer, device trade name, keyword, floating 54629 subheading word, candidate term word]

5 1 or 2 or 3 or 4 57886

6 third wave*.mp. 768

7 "acceptance and commitment therapy"/ 904

8 compassionate mind training.mp. 18

9 functional analytic psychotherapy.mp. 56

10 Metacognitive therapy.mp. 158

11 metacognitive training.mp. 132

12 metacognitive awareness/ 56

13 metacognitive monitoring/ 32

14 mindfulness/ 4750

15 mindfulness* based cognitive therapy.mp. 645

16 MBCT.mp. 479

17 dialectical behavior therapy/ 306

18 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 7081

19 Cognitive Restructur*.mp. 1259

20 Cognitive Intervention*.mp. 1258

21 Cognitive Technique*.mp. 268

22 Cognitive Strateg*.mp. 1578

23 cognitive component*.mp. 1377

24 cognitive method*.mp. 157

25 ((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique$ or 28493 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 212

modif* or strateg* or component*)).tw.

26 19 or 20 or 21 or 22 or 23 or 24 or 25 28640

(behavio*r* adj3 (intervention* or method* or technique* or modif* or strateg* or 27 65386 component*)).tw.

28 (activit* adj3 (schedul* or plan* or arrang* or organis* or organiz* or monitor*)).tw. 43810

29 behavio*r* activation.tw. 1921

30 27 or 28 or 29 110527

31 DEPRESSION/ 326440

32 AGITATED DEPRESSION/ 281

33 ATYPICAL DEPRESSION/ 563

34 DYSPHORIA/ 5633

35 DYSTHYMIA/ 8223

36 ENDOGENOUS DEPRESSION/ 1222

37 INVOLUTIONAL DEPRESSION/ 474

38 MAJOR DEPRESSION/ 54879

39 MASKED DEPRESSION/ 52

40 MELANCHOLIA/ 3369

41 MOURNING SYNDROME/ 123

42 ORGANIC DEPRESSION/ 55

43 PREMENSTRUAL DYSPHORIC DISORDER/ 1149

44 PSEUDODEMENTIA/ 467

45 REACTIVE DEPRESSION/ 434

46 RECURRENT BRIEF DEPRESSION/ 51

47 SEASONAL AFFECTIVE DISORDER/ 1235

48 EMOTIONAL DISORDER/ 16356

49 MOOD DISORDER/ 38548

50 AFFECTIVE NEUROSIS/ 11552

51 BLUNTED AFFECT/ 675

52 MAJOR AFFECTIVE DISORDER/ 387

53 MINOR AFFECTIVE DISORDER/ 60 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 213

31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 54 424577 or 47 or 48 or 49 or 50 or 51 or 52 or 53

55 "randomized controlled trial (topic)"/ 145890

56 Randomized Controlled Trial/ 503163

57 Randomization/ 78433

58 Double Blind Procedure/ 152209

59 single blind procedure/ 31426

60 placebo/ 329613

61 (random* or sham or placebo*).ti,ab,hw. 1790258

62 ((singl* or doubl*) adj (blind* or dumm* or mask*)).ti,ab,hw. 276625

63 ((tripl* or trebl*) adj (blind* or dumm* or mask*)).ti,ab,hw. 973

64 or/55-63 1823062

65 18 or 26 or 30 139473

66 5 and 54 and 64 and 65 1402

67 66 not ((exp infant/ or exp child/ or adolescent/) not exp adult/) 1304

Embase Updated Search

# Search Statement Results

1 cognitive therapy/ 43387

2 cognitive behavioral therapy/ 9019

3 CBT.mp. 15340

(cognitive adj3 therap$).mp. [mp=title, abstract, heading word, drug trade name, original 4 title, device manufacturer, drug manufacturer, device trade name, keyword, floating 60161 subheading word, candidate term word]

5 1 or 2 or 3 or 4 63919

6 third wave*.mp. 859

7 "acceptance and commitment therapy"/ 1159

8 compassionate mind training.mp. 20

9 functional analytic psychotherapy.mp. 58

10 Metacognitive therapy.mp. 189 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 214

11 metacognitive training.mp. 154

12 metacognitive awareness/ 93

13 metacognitive monitoring/ 52

14 mindfulness/ 6742

15 mindfulness* based cognitive therapy.mp. 768

16 MBCT.mp. 566

17 dialectical behavior therapy/ 412

18 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 9546

19 Cognitive Restructur*.mp. 1391

20 Cognitive Intervention*.mp. 1416

21 Cognitive Technique*.mp. 284

22 Cognitive Strateg*.mp. 1709

23 cognitive component*.mp. 1481

24 cognitive method*.mp. 165

((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique$ or 25 32027 modif* or strateg* or component*)).tw.

26 19 or 20 or 21 or 22 or 23 or 24 or 25 32199

(behavio*r* adj3 (intervention* or method* or technique* or modif* or strateg* or 27 72250 component*)).tw.

28 (activit* adj3 (schedul* or plan* or arrang* or organis* or organiz* or monitor*)).tw. 47833

29 behavio*r* activation.tw. 2113

30 27 or 28 or 29 121504

31 DEPRESSION/ 351854

32 AGITATED DEPRESSION/ 292

33 ATYPICAL DEPRESSION/ 596

34 DYSPHORIA/ 5878

35 DYSTHYMIA/ 8689

36 ENDOGENOUS DEPRESSION/ 1228

37 INVOLUTIONAL DEPRESSION/ 479

38 MAJOR DEPRESSION/ 60032 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 215

39 MASKED DEPRESSION/ 54

40 MELANCHOLIA/ 3516

41 MOURNING SYNDROME/ 122

42 ORGANIC DEPRESSION/ 60

43 PREMENSTRUAL DYSPHORIC DISORDER/ 1226

44 PSEUDODEMENTIA/ 475

45 REACTIVE DEPRESSION/ 442

46 RECURRENT BRIEF DEPRESSION/ 50

47 SEASONAL AFFECTIVE DISORDER/ 1303

48 EMOTIONAL DISORDER/ 17450

49 MOOD DISORDER/ 41294

50 AFFECTIVE NEUROSIS/ 11525

51 BLUNTED AFFECT/ 746

52 MAJOR AFFECTIVE DISORDER/ 410

53 MINOR AFFECTIVE DISORDER/ 68

31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 54 457837 or 47 or 48 or 49 or 50 or 51 or 52 or 53

55 "randomized controlled trial (topic)"/ 164418

56 Randomized Controlled Trial/ 561867

57 Randomization/ 83473

58 Double Blind Procedure/ 165437

59 single blind procedure/ 35832

60 placebo/ 348574

61 (random* or sham or placebo*).ti,ab,hw. 1944935

62 ((singl* or doubl*) adj (blind* or dumm* or mask*)).ti,ab,hw. 296096

63 ((tripl* or trebl*) adj (blind* or dumm* or mask*)).ti,ab,hw. 1184

64 or/55-63 155727

65 18 or 26 or 30 1573

66 5 and 54 and 64 and 65 1463

67 66 not ((exp infant/ or exp child/ or adolescent/) not exp adult/) 190 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 216

Appendix B

Medline Original Search

# Search Statement Results

1 CBT.mp. 8844

2 cognitive behavioral therapy/ 21969

3 (cognitive$ adj3 therap$).mp. 30500

4 1 or 2 or 3 32332

5 third wave$.mp. 579

6 "acceptance and commitment therapy"/ 237

7 compassionate mind training.mp. 14

8 functional analytic psychotherapy.mp. 34

9 metacognitive therapy.mp. 101

10 metacognitive training.mp. 81

11 Mindfulness/ 1851

12 mindfulness$ based cognitive therapy.mp. 435

13 MBCT.mp. 341

14 dialectical behavior therapy.mp. 427

15 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 3505

16 cognitive restructuring.mp. 769

17 cognitive strategy.mp. 324

((cognitive or cognition) adj3 (restructur$ or intervention$ or method$ or technique$ or 18 15945 modif$ or strateg$ or component$)).tw.

19 16 or 17 or 18 15954

(behavio$r$ adj3 (intervention$ or method$ or technique$ or modif$ or strateg$ or 20 33493 component$)).tw.

21 (activit$ adj3 (schedul$ or plan$ or arrang$ or organis$ or organiz$ or monitor$)).tw. 33364

22 behavio$r$ activation.tw. 1270

23 20 or 21 or 22 67811

24 Mood Disorders/ 13179

25 Depressive Disorder/ 68331 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 217

26 Depressive Disorder, Major/ 26309

27 Depressive Disorder, Treatment-Resistant/ 843

28 Dysthymic Disorder/ 1110

29 Seasonal Affective Disorder/ 1177

30 Neurotic Disorders/ 17935

31 DEPRESSION/ 102676

32 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 215266

33 randomized controlled trial.pt. 462579

34 controlled clinical trial.pt. 92447

35 randomi?ed.ab. 494828

36 placebo.ab. 189599

37 drug therapy.fs. 2023216

38 randomly.ab. 291464

39 trial.ab. 430374

40 groups.ab. 1801471

41 or/33-40 4230690

42 exp animals/ not humans.sh. 4464699

43 41 not 42 3658385

44 15 or 19 or 23 83992

45 4 and 32 and 43 and 44 728

46 45 not ((exp infant/ or exp child/ or adolescent/) not exp adult/) 652

Medline Updated Search

# Search Statement Results

1 CBT.mp. 9928

2 cognitive behavioral therapy/ 23644

3 (cognitive$ adj3 therap$).mp. 33256

4 1 or 2 or 3 35306

5 third wave$.mp. 651 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 218

6 "acceptance and commitment therapy"/ 294

7 compassionate mind training.mp. 16

8 functional analytic psychotherapy.mp. 39

9 metacognitive therapy.mp. 137

10 metacognitive training.mp. 96

11 Mindfulness/ 2520

12 mindfulness$ based cognitive therapy.mp. 508

13 MBCT.mp. 399

14 dialectical behavior therapy.mp. 502

15 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 4440

16 cognitive restructuring.mp. 823

17 cognitive strategy.mp. 354

((cognitive or cognition) adj3 (restructur$ or intervention$ or method$ or technique$ or 18 17628 modif$ or strateg$ or component$)).tw.

19 16 or 17 or 18 17641

(behavio$r$ adj3 (intervention$ or method$ or technique$ or modif$ or strateg$ or 20 36357 component$)).tw.

21 (activit$ adj3 (schedul$ or plan$ or arrang$ or organis$ or organiz$ or monitor$)).tw. 35858

22 behavio$r$ activation.tw. 1359

23 20 or 21 or 22 73211

24 Mood Disorders/ 13781

25 Depressive Disorder/ 70775

26 Depressive Disorder, Major/ 28155

27 Depressive Disorder, Treatment-Resistant/ 1063

28 Dysthymic Disorder/ 1130

29 Seasonal Affective Disorder/ 1197

30 Neurotic Disorders/ 17960

31 DEPRESSION/ 110294

32 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 226796

33 randomized controlled trial.pt. 485678 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 219

34 controlled clinical trial.pt. 93169

35 randomi?ed.ab. 537015

36 placebo.ab. 199262

37 drug therapy.fs. 2123818

38 randomly.ab. 314573

39 trial.ab. 470257

40 groups.ab. 19333372

41 or/33-40 4497147

42 exp animals/ not humans.sh. 4599832

43 41 not 42 3893176

44 15 or 19 or 23 91715

45 4 and 32 and 43 and 44 806

46 45 not ((exp infant/ or exp child/ or adolescent/) not exp adult/) 728

201805* or 201806* or 201807* or 201808* or 201809* or 201810* or 201811* or 47 2333528 201812* or 2019*).dt,ez,ed

48 46 and 47 90

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 220

Appendix C

PsychINFO Original Search

# Search Statement Results

1 exp Cognitive Behavior Therapy/ 18222

2 CBT.mp. 12058

3 (cognitive adj3 therap$).mp. 39200

4 1 or 2 or 3 41263

5 third wave*.mp. 738

6 "acceptance and commitment therapy"/ 1449

7 compassionate mind training.mp. 32

8 functional analytic psychotherapy.mp. 221

9 metacognitive therapy.mp. 193

10 metacognitive training.mp. 185

11 mindfulness/ 7892

12 mindfulness* based cognitive therapy.mp. 754

13 MBCT.mp. 566

14 dialectical behavior therapy/ 1044

15 DBT.mp. 1296

16 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 11511

17 exp Cognitive Restructuring/ 726

18 cognitive restructur*.mp. 2476

19 Cognitive Intervention*.mp. 1459

20 exp Cognitive Techniques/ 15332

21 cognitive technique*.mp. 2033

22 Cognitive Strateg*.mp. 3116

23 cognitive modification*.mp. 142

24 cognitive component*.mp. 1972

((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique* or 25 30413 modif* or strateg* or component*)).tw. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 221

26 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 41388

(behavio*r* adj3 (intervention* or method* or technique* or modif* or strateg* or 27 56708 component*)).tw.

28 (activit* adj3 (schedul* or plan* or arrang* or organis* or organiz* or monitor*)).tw. 9296

29 behavio*r* activation.tw. 1884

30 27 or 28 or 29 67346

31 exp Major Depression/ 117576

32 exp Anaclitic Depression/ 56

33 exp Dysthymic Disorder/ 1459

34 exp Endogenous Depression/ 1223

35 exp Reactive Depression/ 292

36 exp Recurrent Depression/ 748

37 exp Treatment Resistant Depression/ 1984

38 exp Atypical Depression/ 190

39 exp "Depression (Emotion)"/ 24258

40 exp Seasonal Affective Disorder/ 1027

41 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 141446

42 clinical trial$.mp. 34463

43 random$.mp. 175539

44 placebo$.ti,ab. 36891

45 exp Clinical Trials/ 10895

46 ((clinic$ or control$) adj trial$).tw. 62279

47 Experiment Controls/ 828

48 42 or 43 or 44 or 45 or 46 or 47 215434

49 16 or 26 or 30 109619

50 4 and 41 and 48 and 49 1019

PsychINFO Updated Search

# Search Statement Results

1 exp Cognitive Behavior Therapy/ 19819 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 222

2 CBT.mp. 13062

3 (cognitive adj3 therap$).mp. 41433

4 1 or 2 or 3 43815

5 third wave*.mp. 813

6 "acceptance and commitment therapy"/ 1604

7 compassionate mind training.mp. 36

8 functional analytic psychotherapy.mp. 233

9 metacognitive therapy.mp. 225

10 metacognitive training.mp. 195

11 mindfulness/ 8751

12 mindfulness* based cognitive therapy.mp. 825

13 MBCT.mp. 629

14 dialectical behavior therapy/ 1144

15 DBT.mp. 1423

16 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 12768

17 exp Cognitive Restructuring/ 753

18 cognitive restructur*.mp. 2578

19 Cognitive Intervention*.mp. 1563

20 exp Cognitive Techniques/ 15653

21 cognitive technique*.mp. 2070

22 Cognitive Strateg*.mp. 3251

23 cognitive modification*.mp. 145

24 cognitive component*.mp. 2058

((cognitive or cognition) adj3 (restructur* or intervention* or method* or technique* or 25 32198 modif* or strateg* or component*)).tw.

26 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 43404

(behavio*r* adj3 (intervention* or method* or technique* or modif* or strateg* or 27 59543 component*)).tw.

28 (activit* adj3 (schedul* or plan* or arrang* or organis* or organiz* or monitor*)).tw. 9747

29 behavio*r* activation.tw. 2029 CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 223

30 27 or 28 or 29 70723

31 exp Major Depression/ 123159

32 exp Anaclitic Depression/ 59

33 exp Dysthymic Disorder/ 1469

34 exp Endogenous Depression/ 1225

35 exp Reactive Depression/ 292

36 exp Recurrent Depression/ 776

37 exp Treatment Resistant Depression/ 2131

38 exp Atypical Depression/ 192

39 exp "Depression (Emotion)"/ 24903

40 exp Seasonal Affective Disorder/ 1047

41 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 147633

42 clinical trial$.mp. 43185

43 random$.mp. 195737

44 placebo$.ti,ab. 38215

45 exp Clinical Trials/ 11452

46 ((clinic$ or control$) adj trial$).tw. 67309

47 Experiment Controls/ 841

48 42 or 43 or 44 or 45 or 46 or 47 239861

49 16 or 26 or 30 115744

50 4 and 41 and 48 and 49 1124

51 limit 50 to up=20180528-20190717 65

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 224

Chapter 5 – General Discussion

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 225

General Discussion

Cognitive Behavioural Therapy (CBT) continues to be a thriving area of research.

Treatment guidelines tend to prioritize CBT as a first line treatment for various disorders, including for major depression (National Institute for Health and Clinical Excellence [NICE],

2018). Given the recommendations and prioritization of CBT over alternative treatments, it is arguably important to understand the components or interventions, and unearth what makes this treatment effective in reducing major depression. Furthermore, Wenzel (2017) suggested the need to delineate and examine the interventions, in addition to the larger components, in order to understand the relative impact and importance of types of interventions.

The dissertation involved three manuscripts that explored and examined CBT interventions. More specifically, the manuscripts focused on behavioural activation and cognitive restructuring techniques (Beck & Beck, 2011). Given that Kanter and colleagues (2010) conducted a review on behavioural activation interventions, the first review focused on cognitive restructuring interventions. This scoping review identified and defined cognitive interventions, and extracted clinical recommendations related to the administration of the identified techniques.

Further, this comprehensive review uncovered two types of interventions, (1) cognitive interventions that target automatic thoughts and (2) cognitive interventions that target core beliefs. Given the plethora of data the scoping review was divided into two manuscripts; manuscript one focused on interventions for automatic thoughts, whereas, manuscript two described interventions for core beliefs.

In manuscript one, three overarching types of techniques were identified, including (1) identifying techniques, (2) exploring techniques, and (3) challenging or modifying techniques and several subtypes of techniques were also identified and described. Core clinical CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 226 recommendations were identified for interventions targeting automatic thoughts. Similarly, manuscript two identified and defined two overarching types and a number of subtypes of interventions for targeting core beliefs, and described clinical recommendations. The two overarching groups of interventions included (1) techniques that identify core beliefs and (2) techniques that modify core beliefs. Six clinical recommendations were uncovered that outlined recommendations for administering core belief techniques. Both manuscripts highlighted the need for future research to examine the clinical recommendations.

The first two manuscripts add to the existing literature on therapist techniques in CBT for depression. CBT techniques have been extensively researched and behavioural activation techniques have been systematically reviewed (Kanter et al., 2010). While a plethora of research exists on cognitive techniques, there was an identified research gap in summarizing the data through a review. The manuscripts added to the knowledge base by addressing this gap and produced the first review of cognitive restructuring techniques that included key records going back to the inception of CBT. Each manuscript provided concise definitions and nuances of each technique. Techniques were further organized into themes that have the potential to guide clinicians and researchers. For example, researchers could use the definitions provided in order to operationalize specific techniques in future research. Additionally, past records have discussed general recommendations for the delivery of techniques. However, the scoping review expands on existing knowledge, as both manuscripts provide clinical recommendations that pertain specifically to the timing, and ordering of two groups of cognitive techniques (e.g., techniques targeting automatic thoughts and techniques targeting core beliefs).

The third manuscript examined CBT interventions through a systematic review and meta- analysis of randomized control trials. The review aimed to examine interventions within a CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 227 cognitive behavioural framework delivered individually and delivered in groups. The treatment groups included cognitive, behavioural, and cognitive-behavioural interventions. These interventions were compared, and also compared to third-wave interventions, and control conditions. The results indicated non-significant differences between cognitive interventions, behavioral interventions and cognitive-behavioural interventions in the treatment of depression.

Additionally, when each intervention was compared with a control group, all three types of interventions were significantly more effective in reducing symptoms of depression. These findings suggest that cognitive restructuring interventions and behaviour activation interventions are as effective as combined cognitive-behavioural interventions, which differs from treatment guidelines that recommend first-line treatment of depression as CBT (NICE, 2018). Additionally, the review revealed the paucity of individual studies that compare individual interventions, and third-wave interventions.

Manuscript three contributes to the existing literature on therapist techniques in a number of ways. For instance, there was an identified gap in the literature regarding the efficacy of individual techniques. Past records identified the importance of individual techniques on the reduction of depression (e.g., Socratic questioning) yet the empirical evidence appeared unclear

(Clark & Egan, 2015). The meta-analysis highlighted the limited studies evaluating the efficacy of individual techniques and therefore provides direction for future research (e.g., the need for additional randomized control trials on individual techniques) and for treatment manuals (e.g., reducing the emphasis on the impact on individual techniques in the reduction of depression).

Additionally, the manuscript presents a meta-analysis that examines efficacy of groups of techniques (cognitive techniques, behavioural activation techniques and full CBT). This research provides information that could be taken into consideration when reflecting on and modifying CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 228 existing treatment guidelines, such as the National Institute for Health and Clinical Excellence

[NICE], 2018) guidelines. Furthermore, past meta-analyses indicated a need to include higher quality studies (Cuijpers et al., 2011) and to evaluate techniques delivered in individual and in group therapy settings (Huntley, Araya & Salisbury, 2012). The current meta-analysis addressed these suggestions by including only randomized control trial designs, and examined interventions in both individual and group therapy settings.

There were many identified strengths and limitations in the studies conducted. Day,

Thorn and Kapoor (2011) noted that a vast amount of studies exist that focus on quantitative methodologies and expressed future studies would benefit from incorporating the qualitative approaches as this would allow for a greater understanding of CBT techniques. The scoping and systematic review attempted to address this need by incorporating both more descriptive, qualitative methods as well as quantitative methods. Further, the scoping review provided a thorough and comprehensive qualitative review of articles. Manuscript three provided a quantitative review, examining the efficacy of the techniques across settings (i.e., individual and group therapy).

A strength pertaining to the first two manuscripts related to identifying and describing clinical recommendations. It appears this was the first study to complete a review of clinical recommendations and delineate them as they pertain to (1) techniques that target automatic thoughts and (2) interventions that target core beliefs. Delineating these clinical recommendations provides a helpful guide for trainees and clinicians that can inform how to deliver these techniques. Additionally, these clinical recommendations provide clear recommendations that can be examined in future research. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 229

An additional strength is the focus on Major Depression, an important area of study as this disorder has been deemed a leading cause of disability and early death (Lam, McIntosh,

Wang, Enns, Kolivakis, Michalak, et al., 2016; World Health Organization, 2002). For example, the Canadian Network for Mood and Anxiety Treatment Guidelines (CANMAT) identified depression affects approximately 5% of Canadians each year, which equates to over 1.5 million people annually experiencing an episode of major depression (Lam, et al., 2016). There are different treatments available to those who experience major depression, and these treatments have been deemed as evidence-based treatments for major depression. Despite the availability and efficacy of such treatments, there has not been a decline in prevalence rates within Canada

(Lam, et al., 2016). The dissertation helps to delineate a greater number of cognitive interventions through the scoping review and demonstrates the relative efficacy of additional interventions that may be also considered as first-line treatments, providing the clinician and patient with a greater number of treatments at their disposal.

There are a number of limitations that were identified in completing this research. With regards to identifying relevant studies for inclusion, although measures were taken to reduce bias, it was ultimately up to the discretion of the reviewers which studies were included. This may have introduced some subjectivity and bias as to the included records. Although a strength of the systematic review with meta-analysis was the inclusion of high quality studies (e.g., randomized control trials) this also represents a significant limitation of the study. This criterion led to excluding studies that may have made the results more fruitful. More specifically, a handful of studies that examined individual cognitive and behavioural interventions were excluded on the basis of study design. Expanding on the selection criteria, would have also allowed for additional comparisons. Additionally, the systematic review initially aimed to CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 230 explore the comparator of third-wave interventions. There was a paucity of research that examined third-wave interventions compared to behavioural, cognitive, or cognitive-behavioural interventions in the treatment of major depression. This limited the ability to compare and identify meaningful conclusions related to these specific interventions.

An additional limitation of the systematic review pertains to external validity. The study was designed to examine efficacy and included only randomized control trials of interventions for the treatment of major depression. The inclusion of only highly controlled studies focusing on depression limits the generalizability of the results. For example, major depression is a disorder that often presents with comorbid diagnoses such as anxiety or substance use disorders

(Swendsen & Merikangas, 2000). Within the meta-analysis, each study excluded comorbid diagnoses and thus the interventions’ efficacy when applied to more complex presentations of disorders may differ. Dozois and colleagues (2014) have argued that randomized control trials are the gold standard and that the first step in examining treatments is to evaluate efficacy.

However, these researchers also noted the importance of examining effectiveness. In order to address the low external validity in the meta-analysis, future research should also examine effectiveness of interventions including targeting depression and comorbid diagnoses, in order to generalize results to diverse clinical settings.

The systematic review may have also been limited related to the outcome measures identified for inclusion. Although the research included a common measure for assessing symptoms of depression (e.g., BDI-I and BDI-II), the research may have benefited from exploring additional related variables. For instance, assessing intervention impact on suicidality, self-harm behaviours, and dysfunctional thoughts and beliefs. It is possible that expanding outcome measures may identify meaningful and important differences among groups. Despite CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 231 the limitations identified, the research contained important clinical and future research implications.

Clinical Implications

The manuscripts have noteworthy clinical implications. For instance, the review identified and described various cognitive interventions that are common across manuals. This provides clinicians with a summary and a comprehensive list of interventions available.

Secondly, the study lists groups of interventions and discusses how interventions may be applied together or consecutively. Thirdly, manuscript one and two summarize clinical recommendations specifically for administering interventions targeting automatic thoughts and core beliefs, respectively. The scoping review can function as a tentative guide for trainees and clinicians on what to be mindful of when delivering CBT interventions with patients with depression.

In chapter one, two and three, the importance of specific strategies was identified from the literature on therapist techniques in CBT. For example, Socratic questioning was identified as central to the impact of the approach, and a cornerstone technique (Clark & Egan, 2015).

However, through conducting the meta-analysis there was found to be limited evidence to support the importance of individual techniques. For example, there were limited efficacy studies examining individual cognitive or behavioural activation strategies. Therefore, given the limited support for individual strategies, it is suggested that treatment manuals soften their emphasis on specific strategies and refer the impact of specific strategies more tentatively. Additionally, the results of manuscript three indicated that behavioural activation interventions and cognitive interventions were equally efficacious. Based on these findings, it appears that clinicians and trainees have a greater range of strategies at their disposal to apply in clinical settings. In addition, these strategies (e.g., behavioural activation, cognitive, and combined strategies) CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 232 demonstrated clinically meaningful change in depressive severity in individual and group therapy. These results may suggest that each group of strategies can be applied across treatment settings (e.g., individual and group therapy) in order to reduce depression symptom severity.

Overall, based on the clinical recommendation of manuscript one and two, and the findings of manuscript three, interventions can be applied in combination and flexibly across technique types.

The meta-analysis has implications for treatment guidelines. CBT has been recommended as a first-line treatment for major depression, (National Institute for Health and Clinical

Excellence [NICE], 2018) and related interventions (behavioural activation) as secondary. The review produced findings consistent with Jacobson and colleagues (1996) and past meta-analyses

(Cuijpers et al., 2007; Mazzucchelli et al., 2009) suggesting that full CBT does not appear to produce significantly improved outcomes. Past studies, and the current meta-analysis taken together, may suggest or imply that treatment guidelines may benefit from a review.

The manuscripts have implications for various treatment settings, treatment durations and levels of care. Neuhaus and colleagues (2007) reported that there are various factors that impact treatment response. Some of these factors included, length of stay, number of days and hours per week, private or public sector and payer for service. Patients struggling with depression are treated at different levels of care (e.g., inpatient, partial hospitalization, intensive outpatient and outpatient providers). Within these settings there are variable lengths of stay, for instance inpatient stays tend to be shorter in duration (e.g., one to five days) compared to intensive outpatient (e.g., 90 days). The clinician providing therapy in the inpatient setting tends to have a short duration with the patient and a higher acuity population. Understanding the impact of individual or packages of interventions could inform clinicians on which interventions to CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 233 prioritize. Additionally, in hospital settings, many interventions are applied in a group setting.

The systematic review began to differentiate between settings where the interventions are applied individually or in a group setting. Although there were too few studies identified to systematically compare interventions across delivery type, the study demonstrated how specific interventions can impact the level of depression and attaining recovery.

Future Research

Manuscripts one and two identified core cognitive interventions and clinical recommendations for automatic thoughts and core beliefs. Future research could uncover and review existing empirical evidence for these clinical recommendations, and test each clinical recommendation. For example, specifically examining interventions that target automatic thoughts first and core beliefs later in treatment could provide valuable clinical direction for CBT programs. Additionally, testing the recommendation that indicates administering behavioural activations first and cognitive restructuring interventions second, would provide clarity for timing of administering these specific types of interventions. Testing the clinical recommendation would aid practitioners, inform treatment manuals and help to identify further research direction.

The manuscripts examined patients meeting criteria for major depression and did not explore individual variations or different types of depressive disorders such as episodic versus more chronic depression, and severity of depression. Given that the clinical recommendations identified in the review relate to depression severity and type of intervention, future research could explore treatment resistant depression and compare efficacy of behavioural activation versus cognitive restructuring interventions. Based on the recommendations uncovered, it would CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 234 be helpful to test the whether behavioural activation interventions would have a greater impact on symptoms of depression compared to cognitive interventions in this population.

The dissertation identified a paucity of research that examines important individual interventions. It may be beneficial for manuscript three, the systematic review, to be replicated in the future when there are more studies available to include. Future studies, specifically evaluating the usefulness of cornerstone techniques such as activity scheduling, and homework assignment from behavioural activation and Socratic questioning from cognitive interventions, would allow for a greater understanding of whether these are foundational interventions central to reducing symptoms of depression.

In order to further understand the impact of cognitive interventions, it may be beneficial to examine the effect of these interventions and clinical recommendations with depressive populations that differ in terms of their neurodevelopment and cognitive functioning. For instance, exploring the impact of cognitive interventions compared to behavioural activation interventions with children, adolescents, or older adults, and populations such as those who have cognitive deficits such as a traumatic brain injury. Perhaps, there are important caveats to the delivery with patients struggling with depression who have cognitive developmental differences or impairments. Research uncovering clinical recommendations and testing interventions with these populations may be an important next step.

Conclusion

The current dissertation aimed to identify, explore and examine a range of interventions from a cognitive-behavioural approach. Cognitive interventions were clearly identified and described and the review provided clinical recommendations that have the potential to inform clinical practice. CBT interventions were evaluated and cognitive, behavioural and combined CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 235 interventions were found to not significantly differ. Through conducting this research, several limitations were identified and discussed. Finally, the current thesis had meaningful clinical implications that can inform training programs and clinical practice. The three manuscripts added to the existing research on therapist techniques for major depression and uncovered important future directions for clinical research.

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 236

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Appendix A

Table 1.

Data extraction of records

Record Author(s) & Study Title Publication Design Patient Treatment type Duration of Treatment Number of Sessions Frequency of Sessions Type of Treatment Demographics Number Year Type diagnosis

1 Baer, R. A., Treating acute depression Book None Depression MBCT 2 hour sessions for 8 8 sessions 1/week Group therapy Adults et al. with Mindfulness-based Chapter weeks (2016). cognitive therapy

2 Beck, Cognitive therapy of Book None Depression CBT 1 hr session for 12 weeks 12 sessions 1/week Individual therapy Adults A.T.(1979) depression Chapter

3 Beck, J.S., Cognitive therapy : basics Book None Depression CBT Not specified Not specified Not specified Individual therapy Adults (2011) A and beyond Evaluating Chapter Automatic Thoughts.

4 Beck, J.S., Cognitive therapy : basics Book None Depression CBT Not specified Not specified Not specified Individual therapy Adults (2011) B and beyond Identifying Chapter Automatic Thoughts

5 Beck, A.T. An interview with a Book None Depression CBT Not specified 1 Session Not specified Individual therapy 40 year old et al. (1989) depressed and suicidal Chapter female patient CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 266

6 Berk, M.S., A cognitive therapy Journal Review MDD CBT Not specified 10 sessions Not specified Individual therapy Adults et al., intervention for suicide Article (2004) attempters: An overview of the treatment and case examples.

7 Bieling, Cognitive-behavioral Book None Anxiety and CBT Not specified Not specified Not specified Group therapy Adults P.J., et al., therapy in groups Chapter Mood (2006) Disorders

8 Braun, J.D., Therapist use of Socratic Journal Within- MDD CT 16 weeks Not specified Not specified Individual Therapy female,n=29, et al., questioning predicts Article subject male, n=26; (2015) session-to-session symptom mean age = 37; change in cognitive therapy for depression

9 Clore, J., et Self-statement modification Journal RCT Depression CBT 3 weeks 3 sessions 1x/week Individual therapy Undergraduat al., (2006) techniques for distressed Article students college students with low self-esteem and depressive symptoms

10 Covi, L., et Cognitive group Journal Review MDD CBT 2-hours 15-20 sessions Not specified Group therapy Adults al., (1982) psychotherapy of Article depression: The close-ended group. 11 Dobson, Common change processes Book None Depression CBT Not specified Not specified Not specified Not specified Adults K.S., et in cognitive-behavioral Chapter al.,(1996) therapies for depression. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 267

12 Dobson, Cognitive therapy for Book None Depression CT Not specified 20 sessions Not specified Individual therapy Adults K.S, et al., depression. Chapter (2008) 13 Dowd, E.T, Depression: Theory, Journal Review Dysthymia, CBT Not specified Not specified Not specified Not specified Adults et al., assessment, and new Article unipolar- (2003) directions in practice. depression, bipolar depression 14 Dunn, R.J. Cognitive modification journal RCT Depression CBT 8-weeks 16-sessions total 2/week Individual Therapy n=24, 25-60, et al., with depression-prone Article out-patient (1979) psychiatric patients.

15 Evans, Patterns of personal and Book None Depression CBT Not specified Not specified Not specified Not specified Adults M.D., et causal inference: Chapter al.,(1988) Implications for the cognitive therapy of depression. 16 Eisendrath, Adapting mindfulness- Journal Case MDD, TRD MBCT +ACT 2.5-hour sessions, 8-weeks 8 sessions 1/week Group therapy 49, female, S., et al., based cognitive therapy for Article study married (2011) treatment-resistant depression 17 Fefergrad, Cognitive behavioral Book None Depression CBT Not specified Not specified Not specified Individual therapy Adults M., et al., therapy for depression. Chapter (2013) A Cognitive Restructuring

18 Fefergrad, Cognitive behavioral Book None Depression CBT Not specified Not specified Not specified Individual therapy Adults M., et al., therapy for depression.- The Chapter (2013) B Automatic Thought Record And Questioning CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 268

19 Fennell, Depression. Book None MDD CBT Not specified Not specified Not specified Not specified Adults M.J. et Chapter al.,(1989) 20 Freeman, Encyclopedia of cognitive Book None Depression CT Not specified Not specified Not specified Not specified Adults A.,(2004) behavior therapy. Chapter

21 Freeman, Cognitive therapy of Book None Depression CT Not specified 12-20 sessions Not specified Not specified Adults A., et al., depression. Chapter (1990) 22 Freeman, Cognitive therapy and Book None Depression CT Not specified 12-20 sessions Not specified Not specified Adults A., et al., depression Chapter (1998)

23 Freeman, Cognitive behavior therapy. Book None Depression CBT Not specified 12-20 Sessions Not specified Not specified Adults A., et al., Chapter (1999) 24 Freeman, Comprehensive handbook Book None Depression CT Not specified 15-20 sessions Not specified Not specified Adult A., et al., of cognitive therapy Chapter (1989) Cogntive Therapy with the Adult Depressed Patient.

25 Freeman, Cognitive behavioral Journal Review Depression CBT, ST Not specified Not specified Not specified Individual therapy Adults S.M et therapy in advanced practice Article and anxiety al.,(2006) nursing: An overview. disorders

26 Freres, The Promotion of Optimism Book None Depression CBT 90-minutes 12-sessions total Not specified Group therapy Adults, children, D.R., et al., and Health. Chapter adolescents (2006) (School, out- patient) CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 269

27 Frojan- Analysis of the therapist's Journal Case Depression CBT Not specified Not specified Not specified Individual therapy 29, Female, Parga, verbal behavior during Article study M.X., et cognitive restructuring al.,(2009) debates: A case study.

28 Goddard, Cognitive behaviour therapy Journal Review Depression CBT Not specified 12 - 16 sessions 1/week Individual/Group Adults A.U., et al., and depression. Article (1982)

29 Hallis, L., et Combining Cognitive Journal Review/c MDD, ACT, CBT Not specified 15 sessions Not specified Group therapy mean age = 45 al., (2016) Therapy with Acceptance Article ase study dysthymia, and Commitment Therapy social phobia for depression: A manualized group therapy.

30 Hawley, Cognitive-behavioral Journal Repeated MDD, CBT 2-hour sessions 14 sessions 1/week Group therapy mean age = 41; L.L., et al., therapy for depression using Article - dysthymia 67% were (2017) mind over mood: CBT skill measures female; 37% use and differential were married symptom alleviation

31 Hayes, S.C., Mindfulness: Method and Journal Review N/A ACT Not specified Not specified Not specified Not specified Adults et al. (2003) process Article CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 270

32 Hinton, Cognitive defusion for Journal RCT Dysphoria ACT 1-hour sessions 3 sessions 1x/week Individual therapy Female (n = 16, M.J., et al., psychological distress, Article 73%), Euro- (2010) dysphoria, and low self- American (n = esteem: A randomized 19, 86%), and technique evaluation trial of full-time college vocalizing strategies. students (n = 21, 96%).

33 Holland, S., A cognitive-behavioral Journal Case Depression ACT, CBT Not specified 5 sessions 1x/week Individual therapy Adult male (2016) perspective on Robert Article study and anxiety Psychodynamic Cohen's case of "Daniel.". disorders

34 Hollon, Cognitive therapy for Journal Review Depression CBT Not specified Not specified Not specified Not specified Adults S.D., et al., depression: A social Article (1990) cognitive perspective.

35 Holmes, Mental Imagery in Journal Review Depression CBT, ST Not specified Not specified Not specified Not specified Adults E.A., et Depression: Article al.,(2016) Phenomenology, Potential Mechanisms, and Treatment Implications. 36 Howl, et al., Psychosocial therapies for Book None Dysthymia CT, IPT Not specified Not specified Not specified Individual therapy Adults (1996) dysthymia. Chapter

37 Huppert, The building blocks of Journal Review Depression CBT Not specified Not specified 1x/week Individual therapy Adults J.D. et al., treatment in cognitive- Article and anxiety (2009) behavioral therapy. disorders CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 271

38 Ilardi, S.S., Rapid early response, Journal Review Depression CBT Not specified Not specified Not specified Not specified Adults et al., cognitive modification, and Article (1999) nonspecific factors in cognitive behavior therapy for depression: A reply to Tang and DeRubeis

39 Ilardi, S.S., The role of nonspecific Journal Review Depression CBT Not specified Not specified Not specified Not specified Adults et al., factors in cognitive- Article (1994) behavior therapy for depression.

40 Jacobson, A component analysis of Journal RCT MDD CBT Not specified 12 sessions 1x/week Individual therapy female, n = 110, N.S., et al., cognitive-behavioral Article male, n = 42 (1996) treatment for depression.

41 Jarrett, Mechanisms of change in Journal RCT MDD CBT Not specified 6 sessions 2/week Not specified mean age = 37; R.B., et al., cognitive therapy of Article female, n=29; (1987) depression. male, n= 8;

42 Jarrett, Cognitive therapy for Book None Depression CBT Not specified Not specified Not specified Not specified Adults R.B., et al., depression Chapter (1988) 43 Keefe, J. R., A critique of theoretical Book None Depression CT, ACT, Not specified 10 sessions 1x/week Individual therapy Adults et a;., models of depression: Chapter MBCT (2016) Commonalities and distinctive features CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 272

44 Kellogg, Cognitive therapy Book None Depression CBT 12-16 weeks 12 sessions 1-2/week Individual therapy Adults S.H., et al., Chapter (2008) 45 Keng, S.L., Effects of brief mindful Journal Between Depression ACT 3 weeks 3 sessions 1x/week Individual Age: 18,55, et al., acceptance induction on Article -subject English (2016) implicit dysfunctional Speaking , 43 attitudes and concordance Female,41 between implicit and Chinese explicit dysfunctional attitudes.

46 Klosko, Cognitive-behavioral Book None Depression CBT Not specified 8 Sessions Not specified Individual Adults J.S., et treatment of depression. Chapter al.,(1999) A Session 2

47 Klosko, Cognitive-behavioral Book None Depression CBT 8 weeks 8 Sessions 1x/week Individual Adults J.S., et treatment of depression. Chapter al.,(1999) B Session 3

48 Knapp, P., Cognitive therapy: Journal Review Depression CBT Not specified Not specified Not specified Not specified Adults et al., Foundations, conceptual Article and anxiety (2008) models, applications and disorders research.

49 Kohlenberg, Functional Analytic Book None Depression FAP Not specified Not specified Not specified Not specified Adults R.J., et al., Psychotherapy, Cognitive Chapter (2004) Therapy, and Acceptance CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 273

50 Koster, E. Cognitive Control Training Journal Review Depression CT Not specified Varied Not specidied Individual/Group Adults H., et al., interventions for depression: Article (2009) A systematic review of findings from training studies 51 Lam, D., et Cognitive behaviour Journal Review Depression CBT Not specified Not specified Not specified Not specified Adults al.,(2001) therapy approach to Article assessing dysfunctional thoughts. 52 Lau, M.A., Integrating mindfulness Journal Review Depression ACT, CBT, Not specified Not specified Not specified Not specified Adults et al., meditation with cognitive Article DBT (2005) and behavioural therapies: the challenge of combining acceptance- and change- based strategies.

53 Lewinsohn, The Coping With Journal Review Depression CBT Not specified Not specified Not specified Not specified Adults P.M., et al., Depression Course: Review Article (1989) and future directions.

54 Longmore, Do we need to challenge Journal Review Depression CBT Not specified Not specified Not specified Not specified Adults R.J., et thoughts in cognitive Article and anxiety al.,(2007) behavior therapy? disorders

55 March, et Mindfulness for the Book None Depressive MBCT, MBSR Not specified Not specified Not specified Not specified Adults al.,(2016) treatment of depression. Chapter Disorders CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 274

56 McBride, Major Depressive Disorder Book None MDD CT Not specified Not specified Not specified Not specified Adults C., et and Cognitive Schemas. Chapter al.,(2007)

57 McCulloug Cognitive-behavioral Journal Within- Dysthymia CBT, CBASP 55 minutes mean 32.5; Range= 1/week Individual Therapy n=4; mean age= h, J.P, et analysis system of Article subject 26-42 20 al.,(1984) psychotherapy: An interactional treatment approach for dysthymic disorder. 58 Moore, R. Cognitive therapy for Book None Depression CT Not specified Not specified Not specified Individual Therapy Adults and A. chronic and persistent Chapter Garland depression Working with (2003) Automatic Thoughts

59 Moore, R. Cognitive therapy for Book None Depression CT Not specified Not specified Not specified Individual Therapy Adults and A. chronic and persistent Chapter Garland depression Working with (2003) Automatic Thoughts

60 Mor, N., et Cognitive-behavioral Journal Review MDD CBT Not specified Range = 10-20 1x/week Individual Therapy Adults al., (2009) therapy for depression Article sessions

61 Moretti, Cognitive therapy: Current Book None Depression CT Not specified 20 sessions 1x/week Individual therapy Adults M.M., et al., issues in theory and Chapter and Anxiety (1990) practice. disorders CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 275

62 O'Donohue, Cognitive behavior therapy : Book None Anxiety and CBT Not specified Not specified Not specified Individual Therapy Adults W.T. and applying empirically Chaoter Depression J.E. supported techniques in Fisher,(200 your practice Cognitive 8) Restructuring (14)

63 O'Donohue, Cognitive behavior therapy : Book None Depression & CBT Not specified Not specified Not specified Individual Therapy Adults W.T. and applying empirically Chapter Anxiety J.E. supported techniques in disorders Fisher(2008 your practice Identifying ) and Modifying Maladaptive Schemas (57)

64 O'Donohue, Cognitive behavior therapy : Book None Anxiety and CBT Not specified Not specified Not specified Individual Therapy Adults W.T. and applying empirically Chaoter Depression J.E. supported techniques in Fisher,(200 your practice Cognitive 8) Restructuring (14)

65 O'Donohue, Cognitive behavior therapy : Book None Depression CBT Not specified Not specified Not specified Group and Children, W.T. and applying empirically Chapter Individual Adolescents, J.E. Fisher,( supported techniques in and adults 2008) your practice Attribution Change (5).

66 O'Donohue, Cognitive behavior therapy : Book None Depression, CBT 8 week program Not specified Not specified Group Therapy Adults W.T. and applying empirically Chapter generalized J.E. Fisher,( supported techniques in anxiety 2008) your practice Mindfulness disorder, Practice (40). eating disorders, CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 276

67 Overholser, Cognitive-behavioral Journa Review MDD CBT Not specified Not specified Not specified Individual Therapy Adults J.C., et treatment of depression, Part Article al., (1995) VII: Coping with precipitating events.

68 Perris, C.U., Cognitive therapy with the Book None Depression CBT 45-50 minutes Range= 15-20 1/week Individual Therapy Adults et al., adult depressed patient Chapter sessions (1989) 69 Persons, Schema change methods. Book None Depression CBT Not specified 8 sessions Not specified Individual Therapy Adults J.B., et al., Chapter (2001) 70 Persons, Using the Thought Record. Book None Depression CBT Not specified Not specified Not specified Individual Therapy Adults J.B., et al., Chapter (2001) 71 Petersen, The Massachusetts General Book None Depression, CBT Not specified Not specified Not specified Individul Therapy Adults T.J., et al. Hospital handbook of Chapter GAD, PTSD, (2016) cognitive behavioral Schizophreni therapy. a 72 Piasecki, J., Cognitive therapy for Book None Depression CT 20 sessions for 12 weeks 20 sessions 1/week Individual Therapy Adults et depression: Unexplicated Chapter al.,(1987) schemata and scripts.

73 Roberts, Cognitive rehabilitation Book None Depression CT Not specified Not specified Not specified Not specified Adults J.E., et al., interventions for depressed Chapter (unipolar) (1996) patients CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 277

74 Rude, S.S., The Use of Cognitive and Journal Case Depression CBT, Gestalt 17-weeks Not specified Not specified Individual 32-years-old, et al., Experiential Techniques to Article study (did not meet Therapy female, (2005) Treat Depression. criteria for caucasian, MDD) divorced

75 Rush, A., et Cognitive therapy of Book None Depression CBT 20 sessions over 10-12 Not specified Not specified Individul therapy Adults al.,(1988) depression and suicide. Chapter weeks

76 S., et Cognitive-behavioral Book None Depression CT Not specified Not specified Not specified Individul therapy Adults al.,(2001) therapy of depression Chapter

77 Sacco, Cognitive theory and Book None Depression CT Not specified Not specified Not specified Individual/Group Adults W.P., et al., therapy. Chapter (1995) 78 Schuyler, Cognitive therapy for Journal Case MDD CT Not specified 6-10 sessions Not specified Individual 40 year old D.S. et al., depression Article study male; 45- year (2003) old white female 79 Segal, Z.V., Mindfulness-based Book None Depression MBCT Not specified Not specified Not specified Individual Adults et al., . cognitive therapy for Chapter (2002) A depression: A new approach to preventing relapse Chapter 11: Thoughts are not facts 80 Segal, Z.V., Mindfulness-based Book None Depression MBCT Not specified Not specified Not specified Individual Adults et al., . cognitive therapy for Chapter (2002) B depression: A new approach to preventing relapse Chapter 9: Staying Present CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 278

81 Sudak, Cognitive behavioral Journal Review Depression CBT Not specified Not specified Not specified Individual therapy Adults D.M. et al., therapy for depression. Article (2012)

82 Straarup, Helpful aspects of Journal Qualitati MDD CBT, MCT 50 minutes up to 24 sessions Not specified Individual therapy n = 6; mean age N.S., et al., metacognitive therapy and Article ve = 25.5) (2015) cognitive behaviour therapy interview for depression: A qualitative study.

83 Shaw, B.F., Cognitive therapy of Book None Unipolar CBT Not specified Mean = 20 session N/A Individual Adults et al.,(1993) unipolar depression Chapter Depression

84 Thase, Psychotherapy of refractory Journal Review Major CBT Not specified Not specified Not specified Individual Adults M.E., et al., depressions. Article Depressive (1997) Disorder 85 Thase, M.E. Inpatient cognitive- Book None Depression CBT Not specified 12-20 sessions 1/week or 2/week Individual/Group Adults et al.,(1993) behavioral therapy of Chapter depression 86 Thase, Cognitive behavior therapy Book None Depression CBT 3-6 months Not specified Not specified Individual Adults M.E., et al., Chapter (1995) 87 Thase, M.E. Cognitive behavior therapy Book None Depression CBT Not specified 8-12 sessions Daily Individual Adult Inpatients et al.,(1996) manual for treatment of Chapter depressed inpatients.

88 Thase, M.E. Cognitive behavior therapy. Book None Depression CBT 45-60 (individual) 90-120 6-20 sessions 1-2/week individual/group Adults et al.,(2013) Chapter (group) minutes, 6-16 weeks CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 279

89 Watkins, Concreteness training Journal RCT Major CBM 1.5-2 hours, one week 1 session 1/week Individual therapy female, n=39, E.R., et al., reduces dysphoria: proof-of- Article Depressive male, n =21; (2009) principle for repeated Episode mean age = 35 cognitive bias modification in depression. 90 Wells, Metacognitive Therapy in Journal Case Depression MCT 45-60 min for 6-8 weeks 8 sessions 1/week Individual 4 women, age : A.U.., et Recurrent and Persistent Article study 18-65 al.,(2009) Depression: A Multiple-Baseline Study of a New Treatment

91 Wenzel, A. Basic Strategies of Journal Review Depression CBT Not specified Not specified Not specified Individual Adults (2017) Cognitive Behavioral Article Therapy. 92 Wheatley, I'll believe it when I can see Journal Case Major CBT Not specified 12-16 sessions 1/week Individual females, n=2; J., et al., it: Imagery rescripting of Article study Depressive mean age = 42 (2007) intrusive sensory memories Episode in depression.

93 Whisman, Initial assessment, case Book None Depression CT Not specified Not specified Not specified Individual Adults M.A., et al., conceptualization, and Chapter (2008) treatment planning.

94 Whisman, The importance of the Journal Review Depression CT Not specified Not specified Not specified Not specified Adults M.A. et al., cognitive theory of change Article (1999) in cognitive therapy of depression. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 280

95 Williams, Suicidal patients Book None Depression, CT Not specified Not specified Not specified Individual therapy Adults J., et Chapter following al.,(1989) suicide attempt 96 Williams, The psychological Book None Depression CBT Not specified Not specified Not specified Individual therapy Adults J.M.G.,(200 treatment of depression : a Chapter 4) guide to the theory and practice of cognitive behaviour therapy.Treatment Techniques 97 Williams, Cognitive treatment for Book None Depression CT Not specified Not specified Not specified Individual therapy Adults J.M. et al., depression Chapter (1989) 98 Wright, Learning cognitive- Book None Depression CBT Not specified Not specified Not specified Individual therapy Adults J.H., et al.,( behavior therapy : an Chapter 2005) A illustrated guide.Working with Automatic Thoughts

99 Wright, Learning cognitive- Book None Depression CBT Not specified Not specified Not specified Individual therapy Adults J.H., et al.,( behavior therapy : an Chapter 2005) B illustrated guide.Modifying Schemas 100 Wright, Cognitive therapy. Book None Depression , CT Not specified 5-20 Sessions 1x/week Individual therapy Adults J.H., et al., Chapter Anxiety (2011) disorders, eating disorders & Psychosis CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 281

101 Yiend, J., et Modifying interpretation in Journal Between Depression CBM Not specified Not specified Not specified Individual therapy female, n=26, al.,(2014) a clinically depressed Article -subject male, n =10; sample using 'cognitive bias mean age = 42 modification-errors': A double blind randomised controlled trial.

102 Young, J.E., Cognitive therapy for Book None Depression CT 15 to 25 (50-minute) 15-25 Sessions 1/week Individual therapy Adults et al.,(2014) depression. Chapter sessions

103 Yovel, I., et Examination of the core Journal Between Depression CBT, ACT 10 minutes 1 session 1x Individual therapy College al., (2014) cognitive components of Article -subject Students, cognitive behavioral therapy female, n=93, and acceptance and male, n =49; commitment therapy: An mean age = 23 analogue investigation 104 Zettle, R.D., Component and process Journal 2x2 Depression CBT 12 weeks 12 sessions 1/week Individual female, n= 12; et al., analysis of cognitive Article Factorial mean age= 42 (1987) therapy.

105 Zettle, R.D. ACT for depression: A Book None Depression CBT Not specified Not specified Not specified Not specified Adults et al., clinician's guide to using Chapter (2007) acceptance and commitment therapy in treating depression.

Note. MDD, Major Depressive Disorder; TRD, Treatment-resistant Depression; MBCT, Mindfulness-based Cognitive Therapy; CT, Cognitive Therapy; CBT, Cognitive Behaviour Therapy; ACT, Acceptance and Commitment Therapy;

MCT, Meta -cognitive Therapy; FAP, Functional Analytic Psychotherapy; ST, Schema Therapy; MBSR, Mindfulness-based Stress Reduction; CBASP, Cognitive Behavioural Analysis System Psychotherapy; CBM, Cognitive Bias

Modification; IPT, Interpersonal Therapy; RCT, Randomized Control Trial CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 282

Appendix B

Table 2.

Therapist techniques targeting automatic thoughts

Types Subtypes Clinical Recommendations

Identifying Identifying and Labeling Cognitive Errors 1) Use identification strategies in the early phase of treatment.

Techniques Eliciting Automatic Thoughts 2) Identify automatic thoughts in-vivo as they occur.

Observing and Recording Automatic Thoughts 3) Reinforce the patient when they identify an automatic thought.

Distancing and Decentering

Thought Records

Additional Identification Techniques: Identifying Themes,

Thought Counting and Scaling

Exploring Logical Analysis 1) Introduce automatic thought exploration strategies in the first phase

Techniques Hypothesis Testing of treatment.

Socratic Questioning 2) Spend a greater proportion of time exploring thoughts that are

Questioning highly distressing and believable.

3) Mindfully disperse, vary, and adapt the use of questioning

techniques. CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 283

Challenging Evaluating Automatic Thoughts 1) Use interventions aimed at modifying automatic thoughts in the

Techniques Exploring Advantages and Disadvantages second phase of treatment after applying identification strategies.

Examining Evidence 2) Modify automatic thoughts prior to modifying core beliefs.

Reality Testing 3) Work in collaboration with the patient rather than being overly

Reframing directive.

Reattribution. 4) Encourage the patient to generate more adaptive alternative

Decatastrophizing thoughts.

Cognitive Rehearsal

Externalizing Thoughts or Voices

Fantasizing Consequences

Generating and Examining Alternatives

CBT FOR MAJOR DEPRESSION: THERAPIST TECHNIQUE 284

Appendix C

Table 3.

Therapist techniques targeting core beliefs

Types Subtypes Clinical Recommendations

Identifying Historical context 1) Apply core belief strategies after depressive symptomology has subsided.

Techniques Downward arrow 2) Incorporate core belief interventions in later phases of treatment.

Inventories and worksheets 3) Apply core belief interventions once there is a strong therapeutic alliance.

4) Provide psychoeducation, and normalize the slow and gradual shifting of core Modifying Examining evidence beliefs. Techniques Exploring the advantages 5) Identify core beliefs through the use of multiple techniques. and disadvantages 6) Focus on both adaptive and maladaptive core beliefs, as well as on a limited Using historical tests number of beliefs related to the presenting Continuum method

Alternative beliefs

Positive data log

Note. Clinical recommendations apply to both identifying techniques and modifying techniques.