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Library of Congress Cataloging-in-Publication Data
Names: Eddington, Kari M., author.
Title: Self-system therapy for depression : therapist guide / Kari M. Eddington, Timothy J. Strauman, Angela Z. Vieth, Gregory G. Kolden.
Description: Oxford ; New York : Oxford University Press, [2018] | Series: Treatments that work | Includes bibliographical references.
Identifiers: LCCN 2017040490 (print) | LCCN 2017040860 (ebook) | ISBN 9780190602529 (updf) | ISBN 9780190668792 (epub) | ISBN 9780190602512 (paperback)
LC record available at https://lccn.loc.gov/2017040490
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About TREATMENTS THAT WORK
Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps, inducing harm (Barlow, 2010). Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public (McHugh & Barlow, 2010). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001, 2015; McHugh & Barlow, 2010).
Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This series, Treatments ThatWork, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice.
The manuals and workbooks in this series contain step-by-step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice.
In our emerging healthcare system, the growing consensus is that evidence-based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible.
This Therapist Guide and the companion Workbook for clients address the treatment of major depressive disorder with SelfSystem Therapy (SST). SST is a brief, structured psychotherapy that targets depression resulting from difficulties with selfregulation, a common problem in many people with depression. Thus, the focus of SST is on setting goals and gaining motivation to meet those goals, making it unique among treatments for depression. Grounded in well-established research literature and founded on an evidence-based theory of psychopathology, SST has been shown to be effective in decreasing feelings of self-disappointment and increasing feelings of self-satisfaction. This Therapist Guide outlines each phase of treatment in detail, including case vignettes and examples. The client workbook should be used in conjunction with treatment and provides a description of SST along with helpful worksheets.
David H. Barlow, Editor-in- Chief, Treatments ThatWork
Boston, MA
Barlow, D.H. (2004). Psychological treatments. American Psychologist, 59, 869– 878.
Barlow, D.H. (2010). Negative effects from ps ychological treatments: A perspective. American Psychologist, 65(2), 13–20.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Institute of Medicine (IOM). (2015). Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-based standards. Washington, DC: National Academies Press.
McHugh, R.K., & Barlow, D.H. (2010). Dissemination and implementation of evidence-based psychological interventions: A review of current efforts. American Psychologist, 65(2), 73– 84.
Accessing Treatments ThatWork Forms and Worksheets Online
All forms and worksheets from books in the TTW series are made available digitally shortly following print publication. You may download, print, save, and digitally complete them as PDF’s. To access the forms and worksheets, please visit http://www.oup.com/us/ttw.
Part I Background for the Therapist
Chapter 1 Introduction to This Guide 3
Chapter 2 Theoretical Overview 7
Chapter 3 Is Self-System Therapy Right for Your Client? 25
Chapter 4 Overview of Self-System Therapy Strategies 31
Part II Therapy Phases and Strategies
Chapter 5 Orientation Phase (Sessions 1– 4) 49
Chapter 6 Exploration Phase (Sessions 5– 8) 69
Chapter 7 Adaptation Phase (Sessions 9–15) 97
Chapter 8 Termination and Relapse Prevention (Session 16) 127
References 139
About the Authors 141
Background for the Therapist
CHAPTER 1
Introduction to This Guide
GOALS
■ Discuss why another treatment for depression is needed.
■ Provide an overview of the treatment.
■ Explain who should deliver self-system therapy.
■ Explain the use of the Therapist Guide and Client Workbook.
Depression: Do We Need Another Treatment?
Depression is one of the most common forms of mental illness. The high prevalence rates of depression and its social, physical, financial, and psychological consequences come as no surprise to the mental health professionals in a variety of practice settings who have witnessed its debilitating effects.
Despite the rapid expansion of scientific knowledge in the area of depression, we do not fully understand how the various causal factors— including biological, environmental, cognitive, and motivational— interact. Many pathways can lead to depression.
In the face of this complexity, it is probably unrealistic to expect that a one-size-fits-all approach to treatment is the solution. Experienced therapists know that an approach that works exceptionally well with one client can fail with another. The treatment approach, self-system therapy (SST), described in this Therapist Guide and the accompanying Client Workbook (i.e., Self- System Therapy: Client Workbook), is grounded in decades of research on self-regulation. Self-regulation , not to be confused with emotion regulation, is a motivational process that
involves ongoing comparisons between “the person I am” and “the person I want to be or should be.” The comparison is motivational because when it reveals a mismatch (i.e., “I am not the person I want to be”), people strive to correct it, perhaps by setting or revising goals or by changing behavior.
The process of self-regulation, which is fundamental to all human beings, is the foundation of SST. Research has shown that SST is as effective overall as gold standard psychotherapy (i.e., cognitive therapy) and that it leads to better outcomes for a subset of depressed clients who struggle with self-regulation. The addition of SST to the therapist’s repertoire provides an opportunity to improve and enhance efficacy, which is what therapists strive for. We want to give clients the best shot at ending their suffering.
Overview of the Treatment
Many people with depression have difficulties with self-regulation. Aimed at correcting these difficulties, SST is based on a sound theoretical framework, and the strategies (i.e., overall aims) and tactics (i.e., specific actions) that define SST are rooted in that framework. Although the theory underlying SST is distinct from other forms of psychotherapy in its focus on motivational processes (e.g., how clients go about setting and pursuing their goals as they strive to be the people they want to be), the therapy uses many strategies and tactics that are well established in the field. Therapists who are familiar with other empirically supported therapies, such as cognitive-behavioral therapy (CBT) (Beck, Rush, Shaw & Emery, 1979) and interpersonal psychotherapy (IPT) (Klerman, Weissman, Rounsaville, & Chevron, 1984), can draw on their previous training to implement SST effectively.
Research supporting the efficacy of SST includes rigorously designed, randomized controlled trials comparing it with CBT. The initial trial involved an unconstrained length of treatment (Strauman et al., 2006); a subsequent trial limited the treatment to a maximum of 16 sessions (Eddington et al., 2015). The core components of
SST (divided into three treatment phases as described later in this Therapist Guide and as previously described by Vieth et al., 2003) were delivered regardless of the length. In both cases, the two treatments were equally effective in reducing depressive symptoms overall. However, SST was more effective than CBT for depressed clients with deficits in self-regulation, regardless of whether it was delivered in a time-limited or a less- constrained fashion. In the Therapist Guide, we describe the 16-session format; however, therapists can extend the strategies and tactics of therapy as needed in a manner that is sensitive to each client’s needs.
Who Should Deliver SST?
Therapists who delivered SST during its development and testing varied in their level of prior clinical experience and training. From master’s level trainees to therapists with 15 or more years of clinical experience, numerous clinicians have successfully implemented SST. Training of SST therapists emphasizes understanding of the conceptual framework that underlies each component of the therapy. Because many therapists are unfamiliar with the literature on self-regulation, we provide an extensive background section to inform therapists about the basic concepts of self-regulation. The research literature on self-regulation is vast and complex, but the summary focuses on the concepts that are necessary for implementing SST. Therapists who have experience with short-term, manual-based forms of therapy will feel particularly comfortable with the organization and structure of SST.
Therapists using SST should be responsive to the unique abilities and needs of each client and maintain a spirit of collaboration throughout the course of therapy. When a client does not feel an emotional bond with the therapist or the client and therapist are not working collaboratively on shared goals, the risk for client dropout increases, and the odds of recovery decline. The aspects of the therapy process that cut across all forms of effective psychotherapy (i.e., common factors) are just as important in SST as in any other therapy. As with all forms of psychotherapy, attention to common factors, such as the quality of the therapeutic alliance, is vital.
Use of the Therapist Guide and Client Workbook
The Therapist Guide is organized in two parts. Part I consists of four chapters that provide background information for the therapist. These chapters introduce the theoretical framework, identify appropriate assessment tools and strategies, and provide an overview of SST. Part II contains four chapters focused on implementation. They provide an indepth and highly structured guide to the therapy. Strategies and tactics for each phase of treatment are presented in detail. Each of the chapters describing the three core phases of treatment concludes with a brief section focusing on problems that are commonly encountered in that phase of therapy. We recommend that therapists using SST for the first time read the entire Therapist Guide before starting treatment and then re-read and review the chapters in greater depth during treatment and on pace with the client’s progress.
The accompanying Client Workbook complements the Therapist Guide by providing simple explanations of terminology along with a series of worksheets and guided activities. However, many of the tactics that may be used in SST do not have worksheets due to their idiographic nature. In creating the Client Workbook, we tried to minimize the use of jargon. We selected a handful of terms that are useful for clients to understand and fully engage in this treatment program, and we explain those terms along with examples in the Client Workbook. However, many of the terms we use in the Therapist Guide (particularly in reference to therapy strategies and tactics) do not appear in the Client Workbook. We strongly recommend that therapists familiarize themselves with the Client Workbook and use language in session that is consistent with it.
The Client Workbook is not a stand-alone, self-help book. It was designed to be used in the context of individual psychotherapy delivered by a professional therapist. Recommendations are provided on the use of these materials, but not every worksheet and activity needs to be used with every client. Although SST consists of core strategies that are essential, these concepts and the associated tactics should not be used in a rigid manner.
Theoretical Overview CHAPTER 2
GOALS
■ Introduce the theoretical framework and basic concepts of selfsystem therapy.
■ Describe a model of depression based on deficits in self-regulation.
The Basics of Self- Regulation
Selves and Goals: The Language of Self- Regulation
Because the terminology used throughout the Therapist Guide may not be familiar to all therapists, we begin this chapter by clarifying some key terms and phrases. Clients also may have different ideas about the words and phrases that are used in self-system therapy (SST), and therapists should provide them with clarification. Throughout the Client Workbook, we provide clients with simple explanations of the key terms that are introduced in this section.
Self-regulation involves ongoing comparisons among three aspects of the self: the actual self (i.e., the person I am), the ideal self (i.e., the person I want to be), and the ought self (i.e., the person I should be). We use the term self-beliefs to refer to characteristics that define the actual self and the term self- guides for characteristics that define the ideal and ought selves. Figure 2.1 illustrates the self-system, showing that there are areas of both congruency and discrepancy between self-beliefs and self-guides, which we discuss in more detail later.
Within the conceptual framework of SST, the term self- guide refers to characteristics and attributes such as being funny or being a responsible pet owner. Self-guides can be easily translated into more concrete behaviors and actions such as telling jokes that make people laugh or scheduling regular vet appointments. When talking about self-guides and their associated behaviors, we use the terms goals, standards, and expectations somewhat interchangeably, although we conceptualize each within a hierarchical organization. Standards and expectations tend to be broad, and for the purposes of the Therapist Guide, we use the term standard when referring to a person’s own self-guides and the term expectations when referring to self-guides imposed by others.
The term goal refers to the behavioral manifestations of those broader standards and expectations, similar to operational definitions. For example, a person may have a self-guide concerning being self-sufficient that is defined in part by a standard such as being financially independent. The person also may have more specific goals that define financial independence, such as paying all monthly expenses from one’s own income and never borrowing money from family or friends. This hierarchical structure, with more concrete and specific goals subsumed under broader and more abstract ones, is a well-known feature of how people think about and organize their goals (Carver & Scheier, 1990).
Goals can be described in terms of several dimensions. Goals can be short or long term, depending on the amount of time required to attain them. They can be abstract or concrete, indicating how clearly they
Actual Self (Who I am)
Ideal Self (Who I want to be)
Ought Self (Who I should be)
Figure 2.1
The self-system.
can be defined by specific steps or behaviors. Goals can have different origins; they can be selected and set by the individual (i.e., own) or selected by someone else (i.e., other). An example of a concrete, shortterm, other goal is demonstrated by a client’s statement: “I need to take out the trash because my roommate expects me to.” An abstract, longterm, own goal is illustrated by another client: “I want to become a competitive soccer player because it gives me a sense of accomplishment and pride.”
Unlike specific, concrete goals, such as taking out the trash, selfguides are typically not checklist-type goals that are achieved and then removed from the list. Self-guides, in part because they are broad and abstract, tend to be longer term and ongoing, exerting their effects throughout a person’s life. For example, self-guides of a religious or spiritual nature (e.g., to become a devoted Buddhist) may be lifelong pursuits. Although self-guides may evolve and change over time (e.g., a teenager’s ideal self-guide of being popular may fade by adulthood), people constantly rely on them as important metrics with which to evaluate themselves.
Self- Discrepancy and Motivation
The Actual Self: Who Am I?
Self-regulation is a motivational process involving self- evaluation (i.e., comparisons of self-beliefs with self-guides). One question—Who are you? can elicit a wide range of characteristics and attributes. Some characteristics are descriptive and factual, such as being tall or being a teacher, and may have little relevance when it comes to how an individual relates to others or gets along in the world. However, another question—Who are you in relation to the social world? is different. The answer may be more subjective and situation specific. Ask 10 acquaintances to identify your occupation, and they will all likely come up with the same answer, which will match yours. However, ask 10 acquaintances about who you are as a coworker, family member, or friend, and the answers will vary much more. Some of what you hear may surprise you— the way you see yourself in those roles may be different from how others see you.
Ideal and Ought Self- Guides
If people are honest when asked to define themselves (i.e., Who am I?), there will be some negative characteristics on the list. They may not care much about some things, such as being a terrible cook or a slow runner, but other characteristics may be more important and potentially distressing, such as making impulsive decisions. There may be characteristics on the list that they want to improve (e.g., “I am somewhat patient, but I want to be better”). These characteristics represent possible “selves” that they aspire to attain or feel that they should possess— their self-guides.
Ideal self- guides are characteristics that represent who people want to be in an ideal sense. Ideal self-guides are concerned with aspirations and accomplishments and involve engaging in opportunities that help individuals feel pleased or proud. Ideal self-guides are concerned with trying to obtain a positive outcome (i.e., making good things happen). Ought self- guides are concerned with who people believe they should be. Ought self-guides are concerned with rules, responsibilities, and moral obligations and often involve fulfilling requirements that help people feel more secure or avoid punishment. Ought self-guides are concerned with trying to avoid a negative outcome (i.e., keeping bad things from happening).
The descriptions of actual, ideal, and ought selves discussed in this Therapist Guide come from self- discrepancy theory (Higgins, 1987), which links these core aspects of the self with motivation and emotion. Self- discrepancy theory has a long and rich research history. When there is a discrepancy between the actual self and either the ideal or the ought self that is important to a person (i.e., when the ideal or ought self- guide really matters), negative feelings can result. For most healthy adults, these feelings are motivating— they serve as signals that corrective action is needed. When the corrective action works well, and people are making progress toward their goals (the magnitude of the discrepancy decreases and congruency increases), they experience positive emotions. Generations of psychology researchers have established that goals and standards in general, and self- guides in particular, can have a powerful motivational and emotional impact.
Self-regulation involves cognitive processes that occur continuously and automatically using the accumulated database of self-knowledge, which includes self-beliefs and self-guides. Much of the motivational and emotional impact of self-regulation is determined by how people interpret the consequences of their behaviors. Many life situations are complex, and because there may be no obvious indication of success or failure, people rely on their own perceptions. When a person sees herself as attaining a goal (particularly one that is relevant to an overarching self-guide), positive emotions result. When she sees herself as failing to attain a goal, negative emotions result. Because self-regulation involves the experience of positive and negative emotions as a consequence of being a particular kind of person in line with goals, psychotherapy targeting self-regulation needs to focus intensively on the processes of goal pursuit and self-evaluation.
Research has shown that in the case of depression, the ongoing process of self-evaluation and correcting or changing behaviors does not work properly. As a result, people with depression miss out on important opportunities to feel proud or pleased with themselves and their accomplishments. From a self-regulation perspective, one of the most harmful aspects of depression is that it can fundamentally change how people evaluate themselves, which can result in a long-term vulnerability to negative self-evaluation, distress, and subsequent episodes of depression. Understanding how self-regulation develops and how problems in self-regulation can lead to or result from depression is important for comprehending the rationale behind the strategies and tactics of SST. We begin with an overview of several key concepts in the development of self-regulation.
The Development of Self- Regulation
Self- Regulation: A Social
Learning Process
The roots of self-regulation can be found early in life as children learn how to get their needs met from parents and other caregivers (Higgins, 1999). Children need nurturance and security along with physical protection, and they quickly learn how their behaviors increase or decrease the likelihood that they will get their needs met. For example, when
a child behaves in accordance with parental wishes and asks politely for a snack, the request is granted, and everyone is happy. When the child instead demands a snack in the throes of a tantrum, the request is denied and may be met with frowns and a time-out. The message from repeated experiences of interacting with parents or other adults is clear: “If I am calm and polite, good things will happen (or bad things will not happen).”
Children learn to self-regulate when “good” or “bad” things happen as a result of their behavior.
As they grow, children learn to regulate their behavior so that the good things happen more often and the bad things less often; acting a certain way becomes a goal or standard that guides their behavior. This process of learning contingencies and consequences in interactions with caregivers forms the foundation for how people think about themselves and their standards or personal goals as adults.
Over time, as interactions with parents and caregivers happen again and again, children gradually develop characteristic orientations toward regulating their behavior, and these orientations are typically maintained into adulthood. People tend to self-regulate in ways (i.e., characteristic orientations) that are consistent across situations and contexts. For example, a child raised by parents who emphasize strict adherence to the rules and impose punishment when the rules are violated is likely to learn that paying close attention to the rules and being very cautious or careful helps to avoid punishment (i.e., keeps bad things from happening). This is an adaptive strategy in that context, and the child may generalize the lesson and apply it to new situations, forming the basis of a characteristic orientation. As an adult, the child with that characteristic orientation will continue to approach situations in a cautious way and remain on the lookout for ways to avoid potential punishment.
Characteristic orientations are patterns of self-regulation that are relatively consistent across situations.
Although new experiences occur and new knowledge is gained in adulthood, accumulated knowledge about the self includes motivationally significant early beliefs about how to act or what kind of person to be. Some beliefs become outdated by adulthood and may lie dormant
much of the time. However, especially during times of stress or fatigue, adults may revert to outdated beliefs. For example, a woman raised by parents who withdrew their attention and affection when she did not act feminine enough may know that her current romantic partner does not care about how feminine she is. However, when the couple has an argument, she may, out of learned habit, increase feminine behaviors (e.g., paying attention to her dress and appearance) in order to gain love and affection from her partner, just as she did with her parents. Acting this way may be completely ineffective in the current relationship, but if it is a pattern that was previously reinforced again and again, it may be slow to change. For many people, self-knowledge acquired at earlier levels of development is activated more frequently during times of distress, including episodes of depression, than during times when things are going well.
Self- Knowledge: The Functions of Self- Beliefs and Self- Guides
The originally posed question—Who am I? often can be answered with objective characteristics such as occupation or religious affiliation. However, the larger question—Who am I in relation to the social world? has different and more subjective answers that depend on the social context. As the sense of who we are and how we act continues to develop over time, those characteristics and behaviors can serve different functions (see Higgins, Strauman, & Klein, 1986). The consequences that occur when children behave a certain way as they interact with parents and caregivers represent one such function. When being a certain kind of person leads to specific consequences, that characteristic is serving an instrumental function. This function is not restricted to childhood. For example, a client may believe the following: “If I talk about my problems, I will be vulnerable and end up getting hurt.” Being guarded serves an instrumental function for the client— a protective one.
Other self-knowledge helps people anticipate what will happen in certain situations. For example, people have beliefs about how they will perform on work assignments or how much they will enjoy large parties. These kinds of beliefs serve an expectancy function. Clients with depression are likely to have a preponderance of beliefs about their incompetence, which may be in part caused by a history of chronic
discrepancies between self-beliefs and self-guides. Clients who see themselves as incompetent expect that they will not be able to handle things or will not be successful, regardless of the circumstances. In addition to expectations about performance-type outcomes, people also have beliefs about how they will react to different situations or activities (e.g., “I really enjoy fishing,” “I hate asking someone out for a date.”).
A third possible function of self-knowledge is monitoring. This function is critical to the idea of self-discrepancy and self-congruency. Perceiving a discrepancy between a self-belief attribute and a self-guide (i.e., an ideal or ought standard) leads to a negative emotional state. This state signals the need to take corrective action to reduce the discrepancy. Conversely, to the extent that a self-belief attribute is congruent with a self-guide, the individual can experience a positive emotional state. Self-knowledge provides the necessary information to carry out the monitoring process, which is at the core of self-regulation.
Self- Guides and Their Connections with Promotion and Prevention Goals
Earlier, the concepts of self-beliefs and self-guides (i.e., ideal and ought selves) were introduced. Children learn to evaluate themselves in relation to these two types of self-guides and to develop goals that correspond with them. Following regulatory focus theory (Higgins, 1997), goals that involve trying to make something good happen, such as getting a snack or winning a race, are called promotion goals. Goals that involve trying to keep something bad from happening, such as avoiding a time-out or not failing a test, are called prevention goals. Ideal selfguides are associated with promotion goals, and ought self-guides are associated with prevention goals.
Self-regulation involves two types of goals: promotion goals (i.e., trying to make something good happen) and prevention goals (i.e., trying to keep something bad from happening).
As children move into adulthood, the significant others who provide goal-relevant feedback change. Instead of parents, the significant others may be romantic partners, friends, or coworkers. The self-guides that
people hold and the consequences of being congruent or discrepant with those self-guides also change. For instance, although a teenager may want to be popular, as an adult, he or she may instead focus on being successful. The nature of the goals that adults pursue also may become more complex and difficult (e.g., getting along with in-laws, being a good parent). One of the most important insights of self-regulation research is that a person can construe any given situation as involving either a promotion or a prevention goal:
■ Promotion: “If I am kind and patient around my in-laws, my spouse will be happy, and I will feel pleased and proud of how I handled the situation.”
■ Prevention: “If I can control my irritability and frustration around my in-laws, I will not fight with them, my spouse will not give me the cold shoulder for the next 3 days, and I will feel relieved.”
These examples illustrate a key concept in distinguishing between promotion and prevention goals. If we observed this person’s behavior during a dinner with his in-laws, we would not be able to tell whether he was focused on a promotion or a prevention goal. To an observer, trying to be kind and patient may look the same as trying not to be irritable and frustrated.
Regardless of whether the individual is viewing the situation through the lens of promotion or prevention, his description of the goal for the dinner gathering may be the same: “When I go to dinner with my inlaws, my goal is to get along with them.” The differences that determine whether his goal is one involving promotion or prevention are in how he is thinking about the goal and the possible consequences he anticipates (including the emotional state that will result if he is successful or unsuccessful). Those things are not obvious and are not determined entirely by the situation itself; some investigation would be required to uncover them. Most of the goals that people pursue are not inherently promotion or prevention focused. The motivational focus is imposed on the situation based on how the individual is thinking about it.
As children develop characteristic orientations (i.e., patterns of selfregulation that are relatively consistent across situations), they naturally become more likely to think about situations through one motivational
