1. Chose 1,2,3 models of depression used in Cognitive behavioural therapy. A brief description of each model.
2. Choose the best model and explain why you chose it and why is better than the other two models. Some important characteristics of the model
3. Recent studies e.g. meta analysis evaluating the particular model in treating depression and its various symptoms
4. The efficacy of the model on depression
5. Critical evaluation of the model in treating depression and the symptoms of depression
6. Model’s Strengths and Weaknesses critical evaluation
Literature Review Guide:
• detailed description, explanation and critical evaluation of the CBT model(s) underpinning the interventions
• reasons for choice of model
• theoretical framework underpinning the model
• evidence base from clinical outcome studies
• evidence base from exploratory or experimental studies
• model’s strengths and weaknesses
• adaptations to the model needed for the case
• challenges to treatment delivery
Example
viii. Literature Review In choosing the most appropriate treatment model for Emma, three protocolised interventions for GAD were examined, namely the Intolerance of Uncertainty Model (IUM) by Robichaud and colleagues (2019), Avoidance Model of Worry (AMW) by Borkovec and colleagues (2004), and the Metacognitive Model (MCM) by Wells (2005). They demonstrate similar conceptualisations and theories pertaining to the development and maintenance of GAD. For example, both the AMW and the IUM attribute positive beliefs about worry and negative beliefs about future events to the maintenance of GAD and its associated safety behaviours such as thought suppression (Behar, DiMarco, Hekler, Mohlman, & Staples, 2009). Emma’s presentation fit best with the IUM as she qualified for each of the four aspects of the model, namely intolerance of uncertainty (IU), positive beliefs about worry (PBW), negative problem orientation (NPO), and cognitive avoidance (CA), separately, but also when considering them as non-exclusive, in that IU is deemed as a “higher order process that contributes to the three other model components” (Robichaud, Koerner, & Dugas, 2019, p. 44), maintaining each other in a bi-directional manner, as depicted in Figure 4. Figure 4 depicting the bi-directional relationship of the components of IUM. More recent research provides robust evidence indicating the role of IU as a catalyst for excessive worry and the maintenance of both GAD (Bomyea et al., 2015; Wilson et al., 2020) and symptoms of various emotional disorders (McEvoy, Hyett, Shihata, Price, & Strachan, 2019; Shihata, McEvoy, Mullan, & Carleton, 2016), wherein individuals with heightened IU are more prone to engaging in worrying.
Experimental evidence also reiterates that IU is a risk factor inherent to anxiety due to lack of depressive symptom reduction post treatment for IU, and within anxiety, more specifically related to GAD than other anxiety disorders (Carleton, 2012; Gentes & Ruscio, 2011; McEvoy & Erceg-Hurn, 2016). Clinical outcome evidence demonstrates IU’s mediating effect in treatment of GAD, wherein transtherapy treatment for IU could be associated with symptom relief in GAD (Laposa & Fracalanza, 2019; Fracalanza, Koerner, Deschênes, & Dugas, 2014). This growth of contemporary research determining IU as a cognitive vulnerability in GAD is important to acknowledge as it forms the foundation for the IUM treatment protocol and more recent conceptualisations of the development and maintenance of GAD (American Psychiatric Association, 2013; Hebert & Dugas, 2019; Robichaud et al., 2019).
Intolerance of Uncertainty Positive Beliefs About Worry Cognitive Avoidance Negative Problem OrientationIn establishing Emma’s IU as the cause of not only excessive, chronic worry and anxiety but also her safety behaviours such as PBW, NPO, and CA (Figure 4), the bidirectional nature can explain the maintenance of her GAD-specific symptoms (Britton, Neale, & Davey, 2019; Trouillet, Guerdoux-Ninot, & Jebbar, 2019).
Clinical outcome studies demonstrate safety behaviours as being a commonality across anxiety disorders, with reductions associated with improved CBT treatment outcomes (Desnoyers, Kocovski, Fleming, & Antony, 2017; Kishita & Laidlaw, 2017; Rector, Katz, Quilty, Laposa, Collimore, & Kay, 2019; Vera, Obén, Juarbe, Hernández, & Pérez-Pedrogo, 2021). While the AMW primarily posits that implicit CA strategies for distressing mental images and somatoemotional experiences reinforces the verbal-linguistic nature of worry in GAD (Borkovec et al., 2004), the IUM further postulates that explicit CA strategies are deliberately used to suppress worrisome thoughts, substitute neutral or positive thoughts for worry, distract to interrupt worry, and avoid situations that cause worry (Robichaud et al, 2019, p. 43).
Emma reported using both implicit and explicit CA to manage her worry and anxiety, e.g., ruminating, thought suppression, distraction, thus maintaining her negative beliefs about worry and her ability to problem-solve (NPO). While the MCM also posits that individuals experience negative beliefs about worry, i.e., “worry about worry” (Wells, 2005), it fails to consider IU and PBW as important maintaining factors in GAD.
Emma reported having PBW, insofar that she believed if she didn’t worry, something terrible would happen, and she needed worry to “motivate” her. Evidence implicates the role of IU in maintaining PBW (Robichaud et al., 2019; Hebert, Dugas, Tulloch, & Holowka, 2014). For these reasons, the MCM and AMW were discounted.
ix. Model’s Strengths and Weaknesses As discussed in section viii, compared with the AMW and MCM, the IUM’s conceptualisation of GAD and theoretical foundation is most in-line with contemporary research on IU’s role in developing, maintaining, and mitigating GAD. Evidence from randomised clinical trials in treating IU with CBT have demonstrated significant reduction in GAD-specific symptoms post-treatment and at one-year follow-ups compared to controls in both individual and group settings, with few drop-outs, even with targeted IU therapy (Robichaud et al., 2019; Torbit & laposa, 2016; Vera et al., 2021), suggesting the IUM’s perceived reliability and increasing its efficacy. While there is some evidence of significant reduction in GAD-specific symptom using IUM with large effect sizes and high clinically significant change (Robichaud et al., 2019), there is also evidence that MCM performed better in removing a GAD diagnosis than IUM (van der Heiden, Muris, & van der Molen, 2012). Although there is some evidence regarding continued long-term effects (Robichaud et al., 2019), it is necessary to keep in mind the following points: due to the recency in the development of targeted, disorder-specific CBT interventions, a rather small evidence base backing the treatment outcomes of IUM and other models, and the ongoing updating of the conceptualisation of psychological disorders within the DSM, e.g., GAD, there is a need for further research in order to validate the efficacy of the IUM and other protocolised CBT intervention for GAD. After weighing the strengths and shortcomings, as IUM presents manualised intervention most appropriate for Emma’s case, and having the most recently updated empirical base, the IUM was settled upon for Emma’s treatment.
x. Adaptations to the Model and Challenges In choosing the IUM to treat Emma’s GAD, it was prudent to make adaptations to accommodate her indicative BPD. Dialectical behavioural therapy (DBT) is an efficacious intervention in treating BPD as it’s aimed at individuals who experience greater emotional dysregulation due to heightened arousal (Choi-Kain, Finch, Masland, Jenkins, & Unruh, 2017; Linehan, 2014).
As DBT is considered to be part of the third wave of CBT intervention, adapting the IUM to integrate DBT techniques such as diaphragmatic breathing (DB), self-soothing box, and mindfulness was seamless (see section xii). DBT helped manage Emma’s emotions in session as she found elements of IUM distressing, e.g. imaginal exposure. However, the complexity of Emma’s presentation highlighted a major drawback of IUM, i.e., its highly protocolised nature which offers little flexibility within the designated timeframe. Another challenge that disrupted treatment was a brief suicidal ideation phase (with no intent), exacerbated by Emma’s indicative BPD. Despite these challenges, Emma experiences reliable clinical improvement at the end of treatment (Figures 1 and 3)
