How to Become a More Effective CBT Therapist

Mastering Metacompetence in Clinical Practice

Adrian Whittington, Nick Grey, Adrian Whittington, Nick Grey

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118468371
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

How to Become a More Effective CBT Therapist explores effective ways for therapists to move beyond competence to "metacompetence", remaining true to the core principles of CBT while adapting therapeutic techniques to address the everyday challenges of real-world clinical work. This innovative text explores how to:

• Work most effectively with fundamental therapeutic factors such as the working alliance and diversity;
• Tackle complexities such as co-morbidity, interpersonal dynamics and lack of progress in therapy;
• Adapt CBT when working with older people, individuals with long-term conditions (LTCs), intellectual disabilities, personality disorders and psychosis;
• Develop as a therapist through feedback, supervision, self-practice and training.

II
Handling Complexity

5
Working with Co-Morbid Depression and Anxiety Disorders: A Multiple Diagnostic Approach

Adrian Whittington

I was a driven, ambitious person until five years ago when I broke my back. After that, things I used to think were important weren’t any more. I had to give up work and was in hospital for months. The doctors said that I had been millimetres away from being paralysed. When I left hospital I felt very low. I didn’t know what to do with myself. I felt like the old me was gone. I’m waking a lot in the night with pain and constantly tired. Then I had my first panic attack. These have been going on for a year now. I don’t see how I can build up any kind of life for myself – I just can’t go anywhere outside the house any more. I feel like an attack could strike at any time, even more so when I am tired or feeling miserable. Brian (aged 51)

Introduction

Co-morbidity of depression and anxiety disorders is very common, yet the development of CBT has been marked by the definition and evaluation of interventions focused on single disorders. The interventions with the most robust evidence base have tended to highlight and target a “primary” problem that is the focus of the treatment (although co-morbidity is common in trial populations too). As a result, single-focus specific treatments have been widely disseminated and effective treatment has been provided to large numbers of people with depression and anxiety disorders.

Trainee CBT therapists are often encouraged to learn the application of these approaches with relatively “straightforward” cases where co-morbidity is not significant. However, in routine practice after qualification, co-morbid presentations may not resemble closely these training cases. This can contribute to therapists feeling uncertain about how best to conceptualize, plan and intervene when a client has difficulties with two or more conditions. Co-morbidity can be associated with reduced treatment effectiveness, but is not always, suggesting that some adjustments to single-condition CBT may be more helpful than others.

This chapter reviews the epidemiology and CBT outcome data regarding co-morbid depression and anxiety and suggests procedural rules to apply at assessment, conceptualization and intervention phases of therapy when depression and anxiety disorders occur together. It provides a guide to decision making at each phase, drawing on the evidence base and illustrated with a composite case study of Brian, a 51-year-old man with depression and panic disorder. The chapter focuses on a multiple diagnostic approach to conceptualization, treatment planning and intervention, which for each case applies a combination of disorder-specific conceptualizations and adapts disorder-specific interventions to address multiple problems sequentially. This is distinguished from transdiagnostic approaches to working with co-morbidity, which combine conceptualization and treatment elements into a coherent single approach for application across different combinations of disorders (see Chapter 6 and Chapter 7 in this book). The present chapter makes tentative recommendations about when each approach should be used.

Co-morbid Depression and Anxiety Disorders: Epidemiology and Therapy Outcomes

Co-morbid depression and anxiety disorder is commonplace in the population as a whole, and those seeking treatment. In a large scale US epidemiological survey, 57.5 per cent of those meeting diagnostic criteria for major depressive disorder also met criteria for an anxiety disorder within the same year (Kessler et al., 2003). An English epidemiological study found that the presence of depression was highly correlated with nine other conditions including generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and phobias (McManus, Meltzer, Brugha, Bebbington, & Jenkins, 2009). It was also striking that mixed anxiety and depressive disorder (an ICD-10 diagnosis requiring a disabling level of anxiety and depression symptoms but not meeting full criteria for any other disorder) was more common than all other mood and anxiety disorders put together (McManus et al., 2009). Of those using clinical services, 64 per cent of depressed attenders at a US outpatient clinic also had an anxiety disorder (Brown, Campbell, Lehman, Grisham, & Mancill, 2001). At the same clinic 43 per cent of patients had more than one current anxiety disorder. In addition, multiple co-morbidities of mood and anxiety disorders with other difficulties such as substance misuse, personality disorder or psychosis occur in 2.6 per cent of the population (McManus et al., 2009).

The present chapter focuses on depression and anxiety rather than wider co-morbidities, in order to achieve a manageable scope and as this is where there is the greatest prevalence. People with a combination of depression and anxiety disorder(s) tend to have more severe difficulties, may have increased risk of suicide, and be more likely to relapse than those with depression alone (Andreescu et al., 2007; Keller & Hanks, 1995), yet there has been little attention to designing effective treatments specifically for these types of mixed presentations (Fawcett, Cameron, & Schatzberg, 2010).

A comprehensive review of CBT outcome for treatment of anxiety disorders with co-morbid depression has suggested that co-morbidity can negatively impact outcome, although this effect is by no means universal or total (Bauer, Wilansky-Traynor, & Rector, 2012). This review shows that panic disorder responds well to treatment even when depression is also present, whereas treatment for social anxiety disorder and OCD can be less effective in the presence of co-morbid depression. Evidence is mixed or insufficient to reach any clear conclusion in the case of CBT for GAD and PTSD in the presence of depression. Overall, the evidence does not suggest that disorder-specific approaches to anxiety disorders should be abandoned in the presence of co-morbid depression, but implies that some modifications may be necessary to maximize benefit. There are also consistent findings across disorders that treating a target anxiety disorder is likely to lead to reductions or sometimes remission in the co-morbid depression. A summary of the results of the review across disorders is presented in Table 5.1.

Table 5.1 Conclusions based on Bauer et al.’s (2012) review of CBT outcomes for anxiety disorders with depression

Target disorder	Co-morbid depression as a predictor/moderator of anxiety treatment outcomes	Effect of CBT on co-morbid depression diagnosis and/or symptoms
Panic disorder with/without agoraphobia	Similar rates of improvement regardless of co-morbidity, although some studies show more residual panic symptoms when there is co-morbid depression.	CBT for Panic Disorder can lead to a reduction or remission in depression, although long-term maintenance of these gains is uncertain.
Social anxiety disorder	Higher levels of depression predict lower benefit of CBT for social anxiety including lower likelihood of maintaining gains at follow-up.	CBT for social anxiety disorder can lead to a reduction in depressive symptoms.
Obsessive compulsive disorder	Severe depression hinders treatment gains in CBT for OCD, while milder depression may have a limited impact.	CBT for OCD can lead to a reduction in depressive symptoms, with stronger indications that cognitive therapy can have this effect than behaviour therapy.
Generalized anxiety disorder	Mixed findings – some suggesting that depression predicts a reduced effect of CBT for GAD, others showing no impact and some showing apparent improved outcomes when depression is also present.	CBT for GAD can lead to a reduction in depressive symptoms and reduction in number of co-morbid mood and anxiety disorders.
Post-traumatic stress disorder	Only one case series is reported. A subsequent large UK study not reported in the review found that co-morbid mood disorder was a moderator of PTSD treatment outcome (Ehlers et al., 2013).	CBT for PTSD also leads to reductions in and remission in depression, maintained up to 12 months later.

Treating one anxiety disorder can also impact on the severity of symptoms of other co-morbid anxiety disorders (Brown, Antony, & Barlow, 1995; Tsao, Mystkowski, Zucker, & Craske, 2005) although it appears that such effects can be incomplete, with benefit usually falling short of remission in the co-morbid conditions (McManus, Shafran, & Cooper, 2010).

Co-morbidity shows similar mixed effects on outcome where the treatment focus is depression. Higher levels of anxiety symptoms can impact on the success of either CBT or pharmacological treatment (Farabaugh et al., 2012). However, treating depression can be successful in the presence of co-morbid social anxiety dis...