CBT-based self-management options
Reprinted from "CBT" issue of Visions Journal, 2009, 6 (1), p. 27
As a psychologist in an emergency psychiatric unit, I’ve seen thousands of people in depressive crisis. I have developed an approach to help these individuals who struggle with the bitter suffering of dark mood and despair. It teaches what is known about depression as well as problem-solving strategies.1
About 10 years ago, it dawned on me that if the highly depressed patients I was seeing in the hospital didn’t have basic knowledge about depression, it was likely that people with less severe depression didn’t have this knowledge. This struck me as fundamentally wrong. Surely our health care system could deliver basic knowledge and skills for dealing with one’s own mood. Surely we could teach mood self-management.
From the moment I recognized this gap in mental health services, I committed to getting knowledge and skills for mood self-management to people who were depressed.
A supported self-management scenario:
Thomas, a 25-year-old man, reports to his family physician that he’s been feeling fatigued and low in mood. He’s also been avoiding social gatherings over the few months, since a relationship ended. The physician diagnoses a mild depression. Knowing that antidepressant medication is not recommended for mild cases due to low effectiveness in relation to side effects, the physician provides supported self-management.
In the first session, the physician briefly explains the CBT model of depression, gives Tom a copy of the Antidepressant Skills Workbook and encourages him to read the “Behavioural Activation” section. In a second session a week later, the physician helps Thomas set some initial activation goals, including scheduling a time to contact a friend he hasn’t seen for a few months.
The physician and Thomas have four more sessions over the next couple of months, focused on encouragement and help with goal setting. Thomas uses the behavioural activation to re-establish connection with friends and family as well as to resume some rewarding activities he had dropped. His depression lifts.
Thomas continues to use these skills in subsequent years to manage his mood.
Mood management: CBT to the rescue
A solid body of research shows that providing cognitive-behavioural therapy (CBT)-based self-management material to people dealing with mild depression is an effective intervention.2 There’s also good evidence that adding the element of support increases the positive impact of self-management workbooks.3
The existing self-management workbooks were either costly, inconsistent with available research, too wordy or just not clearly written.
As a scientist in the Centre for Applied Research in Mental Health and Addiction (CARMHA) research group at Simon Fraser University, I created partnerships and looked for support to develop new kinds of self-management materials and training. Fortunately, it has been possible to gain the support of various BC health care agencies in developing and distributing self-management tools and related training. These agencies include the Provincial Health Services Authority, BC Ministry of Health Services, BC Ministry for Children and Family Development, Vancouver Coastal Health, BC Medical Association and Michael Smith Foundation for Health Research.
Our CARMHA research group has developed two basic approaches to making self-management knowledge and skills available to the general public.
We have developed four self-management workbooks. They are free, easily accessible, consistent with research evidence, brief and easy to use.
The workbooks are based on CBT principles for the management of depressed mood. CBT focuses on identifying problems with an individual’s behaviour and thinking, then teaches evidence-based skills for coping more effectively. It deals with current life challenges and stresses, rather than exploring childhood experiences. It is based on that the idea that:
People learn thinking and behavioural coping patterns throughout their lives
Some of these patterns are ineffective in reaching your life goals and may cause suffering
These patterns can be changed through learning coping skills in the therapy situation, trying out these skills in your own life and practising new coping patterns
Our self-management workbooks closely track current research evidence regarding effective CBT treatment principles. The CBT-based skills are clearly explained and taught in a step-by-step way. The workbooks include writing exercises, specific goal-setting and illustrative stories that demonstrate application of the skills.
The four workbooks are described below:
Antidepressant Skills Workbook is our basic depression self-management workbook for adults.
information on how difficult situations, depressive thinking styles, avoidance behaviour, inactivity and other factors can make depression worse
an overview of effective treatment for depression
an explanation of three self-management skills that are helpful for managing depression: behavioural activation, realistic thinking and structured problem-solving (see sidebar)
Antidepressant Skills @ Work is the basic self-management workbook adapted to the challenges of dealing with mood problems in the workplace. It includes information on the effects of depression on work performance—and the impact of workplace stress on depression. It also helps with making decisions such as whether to take time off from your job.
Dealing With Depression is a version of the depression self-management workbook designed for teens.
Positive Coping with Health Conditions is a mood self-management workbook for people suffering from chronic illness. It teaches skills for dealing more effectively with depression, anxiety, anger and social isolation in the context of health conditions.
Each workbook is available for free download from our website at www.carmha.ca/selfcare. Printed copies are also available at a modest cost through a print-on-demand service, contacted through our website. These workbooks have been distributed to approximately 95,000 people.
3 self-management skills:
Supported self-management is provided by trained primary care practitioners such as family physicians or primary care nurses. They provide access to the self-management workbooks, explain the CBT approach, encourage the patient to give it a try and help the patient to set self-management goals (see sidebar).
The physician or nurse is not required to become a CBT psychotherapist, which requires considerable training and a great deal of clinical time. Instead, the health care provider acts as a coach, encouraging and assisting patients.
At CARMHA, we conducted a research trial several years ago to determine whether family physicians would in fact make use of this intervention with their depressed patients. We delivered a brief and very practical training session in supported self-management to a large number of family physicians. The result was very reassuring—this group of physicians delivered the intervention to a substantial proportion of their depressed patients.4-5 The physicians in our study, and many others we’ve since trained, report this intervention to be a useful addition to their practice.
An important feature of supported self-management is that it can be carried out in brief visits. The time pressure on family physicians results in typical patient visits of 10 to 15 minutes. Introducing patients to the self-management workbook, explaining its relevance and supporting use of the skills can be done in a series of brief visits.
What’s crucial is that the patient is reading and using the workbook between physician visits—in fact, most of the important learning and change occurs in the patient’s life outside of the clinic.
It must be kept in mind, however, that for more serious depression cases, supported self-management will not be enough. CBT for more serious cases requires referral to a CBT psychologist (or other provider well-trained in CBT). Still, supported self-management can be used along with other treatments such as medication or treatment by a CBT clinician.
Self-management and supported self-management have the potential to transform care for mild to moderate depression. Family physicians are pleased to be able to deliver CBT-based interventions to many of their depressed patients. This extends the physician’s reach and improves quality of care without significant new health care resources. And patients welcome this new level of access to mental health care.
About the author
Dan is a psychologist who provides consultation to the Centre for Applied Research in Mental Health and Addiction at SFU. He also works in an emergency psychiatric unit at Vancouver General Hospital. Dan oversees an ongoing project to enhance mental health care through brief behavioural interventions for mood disorders
Bilsker, D. & Forster, P. (2003). Problem-solving intervention for suicidal crises in the Psychiatric Emergency Service. Crisis, 24(3), 134-136.
McKendree-Smith, N.L., Floyd, M. & Scogin, F. (2003). Self-administered treatments for depression: A review. Journal of Clinical Psychology, 59(3), 275-288.
Gellatly, J., Bower, P., Hennessy, S. et al. (2007). What makes self-help interventions effective in the management of depressive symptoms? Psychological Medicine, 37(9), 1217-1228.
Bilsker, D., Anderson, J., Samra, J. et al. (2008). Behavioural interventions in primary care: An implementation trial. Canadian Journal of Community Mental Health, 27(2), 179-189.