Cognitive Therapy for Persistent Depression

Richard G. Moore and Anne Garland - Cognitive Therapy for Chronic and Persistent Depression. Wiley, 2003. 436 lk

Tahtsin lugeda midagi psühholoogiast ja Relational Frame Theory ei olnud lihtsalt kättesaadav (eesti raamatukogudes pole, internetis surnud lingid). Kognitiivteraapia sobis ka. Erinevalt RFT-st, mida alles proovitakse empiiriliselt järgi, on kognitiivteraapia järeleproovitud ja aktuaalne. Raamatu keskel hakkas tunduma, et see on terapeudide offshoot NLP-st. Sellele tundmusele aitas suuresti kaasa sõna "model" kasutamine. Vähemasti tundub CT olevat kaugemale arendatud kui NLP, sest manipuleerimine toimub teiste vahenditega. Selle asemel, et uks sisse lüüa ja seinad meelevaldselt üle värvida (NLP), koputatakse uksele viisakalt ja sisse pääsedes tehakse soovitusi, mis värv oleks parem (CT). Raamatu lõpuks tekkis suur tahtmine lugeda teisigi selleteemalisi raamatuid ja omistada parem arusaamine, aga momendil mul selleks aega pole. Sealjuures võtan arvesse CT-le osutatud kriitikat, et "teadus pole kohane perspektiiv, millelt vaadelda emotsionaalseid raskusi". Uurimused on tõestanud, et CT pole oluliselt tõhusam kui ükski teine kliendikeskne psühhoteraapia, aga on saavutanud suurema fiskaalse toetuse just vastupidist väites (kogu raamatust õhkab tegelikult seda so so scientific aurat). Teen siin ka märkuse, et kognitiivteraapial on veel alltüüpe nagu ratsionaal-emotiivne teraapia (RET) ja kognitiivkäitumuslik terapaia (CBT).
Raamatu märksõnadeks on persistent depression, automatic thoughts, modifying beliefs ja vicious cycle. "Süstemaatilised" üldistused olid huvitavad/kentsakad: nt environment, emotion, behaviour, thought ja biology. Nende abil kaardistatakse põhimõtteliselt kogu inimtegevuse sfäär ja kõige arusaamatum sellest tundus bioloogia. Tagantjärgi pole ka imestada - bioloogia all ei mõelda siin mitte rakuehitust ja paljunemist, vaid neuroteaduslikke aspekte (nt drooge) ja mis kõige olulisem - energiat. Siin on minu arvates tehtud sama arutlusviga, mille eest hoiatati funktsionalistliku psühholoogia ajaloos - füüsikaline mõiste "energia" on üle kantud valdkonda, kuhu ta tegelikult ei sobi, ja on kaotanud oma esialgse tähenduse (järgmises raamatuarvustuses toon samamoodi välja selle, kuidas "enesekindlus on hinge energia"). Olulisim infokild sellest raamatust on ilmselt see, et kui sa mõtled negatiivselt, siis sa satud depressiooni (noowaaay!). Lihtne ja huvitav lugemine, aga väga tõsiselt seda ei võtaks (uuesti loeksin küll tho, sest kliendi-küsimused on hästi sõnastatud). Tsitaate:

One further relevant trend in the field of cognitive therapy has been an interest in how patients experience their negative thoughts, rather than simply the content of their thinking. Theoretically, this has been evident in an increase in intrest in metacognition (e.g. Wells, 2000).

Assuming that the therapist manages to maintain their internal sense of motivation to help, appropriately adapting the expression of warmth or care for the patient depends on the development of empathy. In acutely distressed patients, empathy is often achieved through acknowledging and reflecting the patient’s feelings. However, cognitive and emotional avoidance in persistent depression confound the conveying of empathy in this way. For patients who are emotionally flat, it is often unclear what to empathise with. Simply mirroring the emotional flatness of the patient would result in the session grinding to a halt. With an emotionally turbulent patient, reflecting the patient’s emotional state could result in a counterproductive escalation of feelings. In cognitive therapy, conveying empathy depends not just on the mirroring of patients’ feelings, but also on conveying an understanding of how the world looks through their eyes.

Helping patients to become more aware of and better able to identify what they are feeling can contribute to developing empathy with chronically depressed patients. Some patients try not to give the therapist any verbal or gross non-verbal cues (e.g. crying) that they feel upset. The therapist needs to be particularly sensitive to signs of any potential affect shift, including subtle changes in tone of voice, direction of gaze or body posture. Rosemary tended to describe herself as fine when discussing problem situations and would do so in a curt, clipped tone of voice followed by an attempt to return the conversation to more superficial aspects of daily living. The therapist learned to pick up on this and gently to draw her attention to it. Over time Rosemary became more able to recognise and acknowledge when all was not well with her. Other patients react catastrophically to any sign of emotional arousal, perceiving their state simply as ‘awful’ or ‘terrible’. Helping them to discriminate between different negative emotions or different degrees of emotion can help to establish a sense that the therapist understands their feelings without criticising or rejecting them. This process of using feedback to train patients in recognising and labelling affective changes is prerequisite to more conventional expressions of empathy in many cases of chronic depression.

Many patients have been so focused on the issue of whether they will get back to work that they have not fully recognised what they have lost or how this contributes to their depression. It is important that the therapist is explicit in acknowledging the reality of the patient’s losses in relation to work, in order to help the patient to recognise the extent of their losses and even to grieve for them. Many of these losses are tangible and external, whereas others are more symbolic or internal. Working with the patient to validate these can be a useful step in recognising and understanding how thoughts and beliefs, as well as external circumstances, can be contributing to the depression.