Thread: Gerry
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Unread November 12th, 2004, 10:35 PM
James Pretzer James Pretzer is offline
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Default Is CT defined by interventions designed to change cognitions? (Part 2)

Yes, I said that the targeting of cognitive content is warranted in the treatment of depression "because it works and works well" and I think that's a pretty good arguement. However, I don't mean to suggest that we should not continue to try to increase the effectiveness and try to find more effective approaches. A significant number of people do not benefit from CT. Some of these don't get an adequate trial of CT (i.e. they discontinue treatment prematurely) and others show little or no improvement despite an adequate trial of CT. You are completely right that our search for better treatments should not stop. If any of the "Third Wave" approaches turn out to be more effective than "standard" CT, I'll be arguing that we should either switch to those approaches or integrate them into CT.

In addition, we should do some research into the characteristics of individuals who terminate treatment prematurely or show a poor response to CT. I can remember a study or two that suggest that co-occurring Axis-II disorders may account for a substantial portion of these cases. Perhaps we're discovering that when there are co-occurring disorders (Axis-II, substance abuse, marital problems, etc.) we need to treat those problems as well rather than trying to treat the depression in isolation. (Remember that in those well-controlled outcome studies the treatment protocols focus on depression without much attention to co-morbid disorders.)

So why do I continue to emphasise the targeting of cognitive content in the treatment of depression when we have research suggesting that rumination that an important feature of depressive cognition? Because I've seen good evidence that CT based on targeting cognitive content is effective much of the time and I haven't seen good evidence that other treatment approaches are more effective. I've been keeping an eye on the "third wave approaches and will adopt them if they turn out to work better. If any studies showing that they work better have been published, I haven't seen them yet.

You suggest that my stance "raises the question as to why a therapy that seems to have been so clinically liberal in the past (even if this was theoretically incoherent in many ways) seems now to have have lost clinical flexibility when it comes to an apparently indisputable empirical finding". It sounds as though you may have misunderstood my position. I am not suggesting that CT should be inflexible or that we should only focus on changing cognitive content. I'm very much in favor of clinical flexibility and of adding new intervention techniques to CT (while remaining theoretically coherent). Personally, in addition to working to modify dysfunctional thoughts and beliefs, I also target depressive rumination, use a number of DBT techniques, use acceptance-based interventions, and am starting to use mindfulness more frequently. However, I don't buy the idea that we should abandon interventions that focus on cognitive content for some reason since those interventions are effective with many clients.
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