「うつが病気であるという神話─薬物治療の限界と代替策」2-3

Pocket

Allan M. Leventhal and Christopher R. Martell, The Myth of Depression as Disease: Limitations and Alternatives to Drug Treatment (Praeger Publishers, 2005)の読書日記の続きです。読書の備忘録みたいなものですから、ほかの人が読んでもいまいち内容をつかめないかと思います。申し訳ないですm(_ _)m

うつは「病気」ではないので薬では治りません。うつは不安を引き起こす状況を避けることで生じる気分状態なので、その行動を改善させる必要があります。
The hallmarks of depression are a shutting down of activity, negative views of oneself, and negative views regarding the future. A major theme to this book is that the typical client diagnosed as depressed has been misdiagnosed and mistreated. This is because there is reason to believe that depression is better conceptualized not as a disease but as a mood state and behavioral state that has developed from the consequences of avoiding anxiety-provoking situations, perhaps including unlearned biological susceptibilities in the form of temperamental factors. Again, this is not a matter of splitting hairs; it is a very different explanation than the one that views depression as a primary condition of biological origin. Effective treatment of depression, just as has been outlined for the anxiety conditions, requires addressing how the avoidance behavior is occurring. (p.102)

One must remember that human reactions are intensely specific; they involve neural firing of very complex yet specific brain cells and systems. Psychotropic medications now and into the future may not be sufficiently specific or idiographic to meet the individual’s precise needs. That is, they may[wash over the brain] but not target the very specific locations of the brain related to the individual disorder in question. Once put into the system, drugs do not vary in strength and concentration over short periods of time. Behavior, moods, emotions, and thoughts do. Targeting behavior change directly—in other words, changing actions, facial expressions, posture and musculature, and thought patterns—may be a more effective way to change the brain cells and systems associated to that response system. Why not? All behavior is biology. Changing behavior is changing biology. The advantage is that the change is specific, idiographic, and time sensitive. (p.x)

そこでLeventhalとMartellは行動療法(behavior therapy)を提唱します。
Exactly what is meant by behavior therapy? Behavior therapy is defined as the application of experimentally derived principles to modify human behavior that has been classified as deviant. It is a collection of specific techniques, for the most part derived from learning principles, that are applied to effect behavioral and emotional change within the context of a social situation comprised of a therapist and a client. It is not simply a collection of procedures, but an integrated treatment methodology under an umbrella theoretical framework. (pp.121-2)

薬物療法と異なり、行動療法は実験研究によりその有効性が示されています。副作用もありません。治療終了後の再発も薬物療法に比べてはるかに少ないです。
Fortunately, a ray of hope in this picture is the existence of an alternative treatment—behavior therapy that has been demonstrated to have as much or more success than drugs. Studies have shown that behavior therapy provides remedies that are longer-lasting and pose no concerns regarding side effects. Unlike the drug treatments, behavior therapy has evolved out of a solid base in research. The behavioral therapies are based on a different conceptual model, a learning model that looks at the context in which the disorder occurs and that appears to have greater merit in explaining the basis for depression (and other mental disorders). Furthermore, this model indicates specifically how depression should be treated by accounting for the disorder as the outcome of avoidance behavior, a well-understood process by virtue of a great deal of behavioral research. One behavioral treatment, behavioral activation, has been shown to yield particularly good results. Another behavioral treatment, cognitive-behavioral therapy, was also found to yield very good results. CBT attends to thinking as part of the treatment and has been widely studied, validated, and disseminated. (p.137)

We know that behavioral treatment has consistently shown superiority in its endurance following treatment when compared to drug treatments. Relapse is common after withdrawal of drugs, whereas behavioral treatment, because it teaches new coping behaviors, retains its value far better after treatment has ended. We also can point to a sound theoretical and empirical basis for the behavioral treatments, with substantiated mechanisms governing the approach, that is absent when it comes to pharmacological therapy. Unlike drug treatment, behavioral methods have been developed out of lines of empirical research that led to the specific techniques developed and give credence to these techniques. Finally, while there is reason in double-blind studies to point to the physical effects of the drug inducing a placebo effect rather than a real effect, there is no question about the reality of the adverse physical side effects of these drugs. The behavioral treatments pose no such immediate, and perhaps later erupting, dangers. (p.129)

薬物治療は生物学的な観点に基づきますが、その問題点が指摘されています。相対立するのが行動的な観点に基づく行動理論(behavioral theory)です。
Throughout this book we have been examining the two conflicting theories to account for depression—the biological theory and the behavioral theory. From a biological viewpoint, depression is seen as a disease entity with an underlying physical basis. Aside from the problem that the diagnosis of depression is far from reliable, there are other problems with this conceptualization: (l) There are no homogeneous symptoms of depression, (2) there is an implied discontinuity between [normal] mood states of sadness and [abnormal] mood states of depression, and (3) such a viewpoint ignores how the person’s life situation is related to depression. It may be true that people become sad, lethargic, and withdrawn following a loss, and medication may alleviate some of these symptoms, but few reasonable physicians would prescribe medication to take away the normal experience of grief. However, when the feelings have continued for too long, based on either a cultural expectation that a person should have moved forward or the person’s distress over feeling distress, medication would typically be suggested. The implication is that an illness has developed, ignoring the multiple ways that people experience life based on their reinforcement histories and developmental experiences. These are some of the reasons behaviorists take issue with the biological explanation. (p.117)

From a behavioral standpoint, depression is the outcome of behaviors governed by unfavorable reinforcement contingencies. Depression reflects insufficient positive reinforcement for adaptive activities, with reinforcement occurring instead for behaviors that are maladaptive. (p.118)

Depression is regarded as occurring when the net gain associated with responding adaptively is lower than the gains from inactivity. The resultant cognitive features of inactivity, reduced self-esteem, helplessness, and hopelessness are what characterize depression. (p.118)

うつ病の人はセロトニンやドーパミンがあまり出ていないとしても、それがうつの原因ではなく、うつの結果としてみるのが行動療法です。
While much has been made of how behavior (depression, for example) is determined by neurotransmitters, there is as much reason to believe that neurotransmitters like serotonin and norepinephrine are affected by behavioral acts. Whenever you think about a past event, or when you move your legs to walk, something changes in your brain. When a danger is present, the brain reacts by sending messages to the nerves throughout the body to protect you, a signal rushes blood to the extremities, and the muscles become tense. Learning takes place in response to those signals and in response to the salient environmental cues. We have some reason to believe that levels of neurotransmitters are associated with shifting moods. However, as noted in Chapter 2, there are no clear data to indicate that increases or decreases in neurotransmitter levels cause depression, result from it, or reflect some other process basic to both. (pp.59-60)

フロイトらの精神分析学(psychoanalysis)ではうつの症状は幼少時のトラウマ的経験から生じると考えます。しかし、精神分析学の有用性を示す実証的証拠は出ていません。
Psychoanalysis represented a psychological expression of the medical model. Psychoanalytic theory postulates that symptoms are simply by-products of an underlying hidden cause stemming from experiences in early childhood that have produced unconscious psychic conflicts. Treating the person’s behavior instead of these underlying psychic conflicts was condemned as superficial, useless, even harmful, and doomed to failure. The evidence for this proposition was given in case reports. No empirically based outcome studies of the efficacy of psychoanalysis have been conducted, although it is still practiced throughout the world. (p.6)

Over time, it became clear that there were major problems with psychoanalytic theory and practice. Most importantly, it didn’t work very well, or did so only after many years of therapy Its research base consisted of anecdotal case reports that lacked scientific merit. Psychoanalysis does not measure clinical outcome by symptom change; thus, methodologies for assessing treatment outcome have not easily been applied to the model. When changes do occur, often after many years of treatment, the change may be attributable to the therapy, the passage of time, maturation of the client, and so on. It is difficult to know whether the therapy was responsible for the positive changes. The high cost and limited effectiveness of classical psychoanalysis led to its demise as the primary method of psychotherapy. Psychoanalysis is still practiced today, and it remains intellectually compelling to many therapists and clients. Empirical support for the premise of the theory and treatment is yet to be published, despite many scholarly works on the theory and its application to complex problems. (pp.94-5)

精神分析学に代わって現れたのが、生物学的・行動的・環境的影響の相互作用が人間の行動を決定づけると考える生物心理社会的理論(biopsychosocial theory)です。
A far better approach to understanding human behavior can be found in a biopsychosocial theory that recognizes biological, behavioral, and environmental influences in determining human behavior. Genetic and biological influences may play some role in problems such as depression by setting varying thresholds of reactivity, but life experiences and the learning that has taken place in a context of responding to life’s demands show the greatest influence on depression (Antonuccio, Danton, & DeNelsky 1995). In other words, some people may indeed inherit a susceptibility to develop certain problems, but without an interaction of life experience and environmental factors such a predisposition would be unlikely to affect them. Moreover, it is very difficult to determine what is inherited and what is learned. Just because depression may have been diagnosed in family members going back several generations, all we can know is that behavioral patterns, life philosophies, and DNA have been passed down. To say that any one of these factors trumps all of the other contributions is hopelessly reductionistic. (pp.30-1)

うつの原因は様々あるが、著者はうつが生じる一番の理由は「回避行動」(avoidance behavior)にあると主張します。<大きな出来事→ネガティブな反応→ネガティブな感情の回避→回避が生み出す生活の制約>というプロセスをたどってうつは生じます。
Depression is the result of many variables, including perhaps certain predispositions to blue moods or melancholy, early environment, learning history and development, and ongoing cognitive and behavioral patterns that exacerbate and eventually create the problem. There is considerable reason to understand depression as a response to difficulties in life prompted by avoidance behaviors that interfere with people making use of their abilities to accomplish goals that are important to them. (p.33)

So now we return again to the crux of this book. Why do people become depressed? Are you depressed because you have a chemical imbalance? Although neurotransmitter levels appear to be associated with depression, there is little evidence to suggest that they cause depression or anxiety or other disorders. Is negative thinking the culprit? Insofar as our thinking, the words we speak to ourselves, are associated with negative experiences and take on the aversive properties of those experiences, thoughts certainly contribute to negative mood. Is depression your problem at all? Are you one of the thousands of people who experience both depression and anxiety and possibly become obsessive about keeping your house neat or ruminate over your heartaches and losses? Our answer is this: a plethora of data exist to suggest that depression is the result of life events, negative responses to life events, avoidance of negative emotion, and the limitations on life that avoidance creates. (p.131)

「回避」は「恐怖症」(phobia)で典型的に現れます。
Avoidance is most obvious in phobias. A young man who is afraid of heights will go out of his way to avoid crossing a bridge, walking up a ladder, or looking over the edge of a skyscraper deck. People with phobic fear of dogs cross to the other side of the street when they approach someone walking a large pet; people with snake phobias refuse to go through tall grass; claustrophobic people will not meet someone in an office that has no window; those afraid of elevators take stairs; and the list goes on. (pp.63-4)

回避行動によって生じたうつを治すためのもっとも適切な方法は、うつ病患者に回避しているものに直面させることです。
The important point is that avoidance behavior is rooted in the immediate consequences of its occurrence, which had value for primitive man, but in modern-day life, immediate relief often yields a dysfunctional solution because the long-term consequences are negative. Fear of flying may be solved by deciding not to fly, but because there often are worthwhile reasons to travel by air, the long-term consequences are unfortunate. Research, and in many ways common sense, tells us that the best way to conquer a fear is to face it, and an abundant literature in psychology describes how fears can be conquered by exposure rather than avoidance (Foa & Kozak, 1986). (p.64)

What happens in all of the anxiety disorders is this: Upon encountering the feared situation, anxiety begins to rise. Studies have shown that if the individual were to stay in contact with the feared stimulus, the anxiety would reach a peak and then begin to abate in a process called habituation. Extinction (which also is discussed in more detail in the next chapter) and habituation are related. Habituation and extinction describe how a response diminishes with repeated exposures to a stimulus without reinforcement. The point is, if a person can be enabled to stay in a feared situation long enough, his or her fears will diminish. (p.64)

What makes it so hard to stay in a situation in which one is afraid? When it comes to avoidance behaviors that are regarded as disorders, one can offer the psychological or cognitive explanation that a person is anticipating greater danger than is truly present. Regardless of how one accounts for the negative emotional state, perhaps surprisingly, the truest answer is that the person is afraid because of avoidance. Consider what is taking place for such a person: Once avoidance learning takes place, the individual—in that context, with those internal stimuli—is now reacting very importantly to him- or herself in that situation. It is ironic that the avoidance behavior is maintaining the problem rather than relieving it. Successful therapy depends on finding means to enable continued contact with the feared stimulus rather than avoidance in order for the avoidance behavior to be unlearned and more functional behavior learned in its place. Learning how to respond successfully requires staying in the situation. Often it is the case that recognizing that one already knows how to respond successfully also requires staying in the situation. The good news is that there is an emotional payoff for finding the courage to do this. Overcoming the fear increases self-confidence. A person with a fear of heights, who through a series of therapeutic efforts overcomes that fear, often experiences a giddy sense of increased self-regard. (p.65)

Sadness and disappointment are normal reactions in life that ordinarily are temporary. Depression occurs when these states become long-term. Depression is better conceptualized as a mood state that can be induced by anxiety-driven responses, particularly avoidance responses. Two ingredients are common in this process: (l) self-negation and (2) avoidance of engaging in those behaviors that are necessary to overcome elements that are at the heart of the sadness. Of these two factors, avoidance of the behaviors is by far more important to the continuation of depression. Medication is directed at changing self-negation—that is, essentially the mood-state per se. (p.67)

Following the paradigm of anxiety, it is not the reaction to negative life events in itself that is usually a problem, but rather the reaction to the reaction. (p.69)

Depression is often characterized by negative thinking and devaluation of oneself. As in anxiety, there may be an overestimation of potential harm that causes one to be wary and apprehensive. In depression, one may have a tendency to attribute problems to failures in the self that are fixed and stable. In other words, one may begin to see oneself as a [failure] or a [loser.] This type of thinking can, in turn, lead to decreases in coping behavior. Again, this is the crucial factor: avoidance of engaging in the behaviors that are called for as a consequence of negative feelings about self. When thinking about going for a job interview leads to anxiety over anticipated failure and causes the person to avoid the interview, the seeds are present for depression to develop. As the negative valuation of the self continues, hopelessness ensues. Hopelessness has been correlated with greater intensity of depression and with suicidal behaviors (Beck, Resnick, & Lettieri, 1986). Thus, the hopelessness, lethargy, ruminative thinking, and general inertia continue to keep a person locked in a continuing spiral into depression that feels more and more [physical] to him or her. It may be that significant life events and this downward spiral also have an impact on the levels of neurotransmitters in the brain, but there is no good reason to believe that the problem started there. (p.71)

Wanting to escape from negative experiences can lead to many problems. Psychoanalysts for years talked about repression and considered it highly problematic and as leading to multiple symptoms. Although behaviorists do not speak in those terms because such abstract phenomena are not easily verified empirically, it is still clear that one may replace adaptive with maladaptive behaviors in order to avoid the negative experiences of life. In order not to feel scared, one often has to restrict one’s movements; not to feel hurt, one may choose to avoid getting involved in close relationships; to avoid feeling rejected, one may not pursue goals. Keeping oneself in safe situations, socially isolated or underemployed, may allow one to avoid feeling fearful or overwhelmed, but it can also lead to feeling depressed when life does not work out as one would hope. (p.72)

行動セラピー(behavior therapy)は医師と患者の関係を重視するフロイト流精神分析とはちがい、患者の不適応な行動(maladaptive behavior)を変えることでうつ状態を改善しようとします。
1.
Relative to psychotherapy, behavior therapy focuses on the maladaptive behavior itself. There is no presumption of an underlying cause. It does not follow the medical model. Symptoms are viewed as examples of the problem, not as a superficial manifestation of the problem.

2.
Behavior therapists assume that the maladaptive behaviors were acquired as a result of the same principles of learning as any other learned behaviors. Excluded, of course, are behaviors that result from a physical trauma, such as physical and mental dysfunctions that arise as a consequence of accidents that have damaged the central nervous system.

3.
Behavior therapists assume that psychological principles, particularly principles having to do with the learning process, can be used effectively to reduce maladaptive behavior.

4.
Behavior therapists set specific, clearly defined goals in treatment rather than abstract concepts such as [increased maturity] or [personality development.] A specific behavior that is presumed to be interfering with the person’s functioning is targeted for change. Similar to medicine in which the presenting problem may be [I’m feeling poorly] and the doctor seeks to discover the specific ailments that are giving rise to this report, a behavior therapist seeks to identify behaviors that give rise to a self-description of [My life isn’t worth living.]

5.
Behavior therapists design their treatment to address the particular presenting problem. Most other forms of psychotherapy provide essentially the same approach to all who enter treatment. If a therapist presumes that psychological disorders are the result of an underlying, unconscious process, he or she is not likely to view the presenting problem as what is truly important. A behavior therapist’s goal is to remedy the problematic behavior at issue by utilizing different procedures depending upon the nature of the problem. Desensitization may fit one kind of problem, assertiveness training another, skill development another, and so forth.

6.
The behavior therapist attends to the here and now. Most other forms of psychotherapy take early childhood experiences as very important and spend a good deal of time discussing those experiences as a means of effecting change. They seek to [uncover] these experiences to gain [insight] as the means of effecting change. Behavior therapists are far more interested in the present, and they don’t believe that achieving insight is effective. Behavior therapists believe that the remedy comes from the patient behaving differently in crucial situations. When they do look into experiences that contributed to the learning of maladaptive behavior, they do so in the service of identifying present behaviors to be changed rather than dwelling on the past as particularly helpful in its own right.

7.
The techniques of behavior therapy are those that have been subjected to empirical tests and found to be helpful. Behavior therapists do not assume that a technique is helpful because it is derived from a well-accepted theory, but rather because it has demonstrated effectiveness empirically. This is perhaps the single most definitive feature of behavior therapy in contrast to other forms of psychotherapy. (pp.98-100)

不安障害から生じるうつには2つのタイプがあります。
The depressive effects of avoidance behavior are manifested in two ways. The first type of manifestation (let’s call it Type A) occurs as a consequence of some alteration in a person’s life situation that results in a disruption of that person’s previously quite functional ongoing behavior. Typical examples are depressions that occur after the death of a loved one or the loss of income and status following a job loss. In these instances, the person has been cut off from positively reinforcing activities because of the loss and has not found a way of replacing them. Life is no longer happy, and there is no sense of the possibility of a happy future. These are simpler conditions to diagnose and to treat because the cause of the problem is obvious and because what is called for is the reinstatement of previously learned behaviors that are already present in the person’s repertoire but are not being expressed. Behavioral activation aims to promote lost behaviors that had been sources of positive reinforcement. (p.109)

The second kind of life situations that give rise to depression, Type B manifestations, are more complex and numerous. They are found in conditions where avoidance behavior is part of the person’s characteristic way of life, compromising desired goals and gradually producing consequences that lead to depression. … People who suffer from social anxiety, who fail as a result to learn successful social behavior or who fail to achieve their vocational aspirations and eventually become depressed are examples of this Type B manifestation of depression. Because there is no defining event—such as a death or a job loss—that is a readily recognizable precipitant of the depression, more information is necessary to the conduct of therapy to identify the avoidance pattern. Establishing the basis for the depression generally takes longer, but ordinarily a few therapy sessions suffice for the diagnostic process to discover the pattern. In addition, because there generally is a deficit in the person’s functioning that has resulted from the avoidance, therapy must be directed toward correcting that deficit. Rather than reinstating behavior that had been ongoing, as in Type A manifestations, the therapy is aimed at teaching the person how to cope with the specific anxiety-provoking situations that have been avoided. For these reasons, therapy for Type B manifestations usually takes longer. Again, behavioral activation is a treatment for depression that is predicated on replacing avoidance behaviors with successful coping behaviors. (p.110)

行動療法は機能モデル(functional model)に基づいています。
To reiterate, the theoretical model on which these case analyses are based is not the medical or disease model, but a functional model. Whereas the medical model specifies disorder as the result of some underlying and often hidden cause, the functional model views disorder as controlled by learned sequences of behavior, with the important elements open to observation. What is important in a functional model is the relationship between a behavior, its immediate antecedents, and its immediate consequences. (p.110)

The problem to be addressed in therapy is conceptualized as changing a particular behavior occurring under particular circumstances— most importantly, avoidance behavior. The significant antecedents to this behavior are comprised of a complex of intentions and emotions within which a particular constructive response has come through learning to stimulate a negative emotional reaction. As a result, this context sets the occasion for that person to emit a different response, an avoidance response. The immediate consequence of the avoidance behavior is a reduction in the aversive emotional state (anxiety), which results in the avoidance behavior coming to predominate. Simply put, to reduce the fear, the person avoids. As outlined in Chapter 4, the mechanism controlling this process is the principle of negative reinforcement. The avoidance behavior produces mental disorder because, while the immediate effect of avoidance is reinforcing, the long-term consequences of avoidance are dysfunctional. (pp.110-1)

The entire explanation in this model rests on the relationship that exists within a current sequence of experiences and behaviors. Knowing the history of how this sequence was learned can be helpful in defining the problem and may be of intellectual interest, but it is of no pragmatic value in itself. Although a thorough understanding of the learning history or [insight] might be nice, this model indicates that the only satisfactory remedy is one that rests on changing the person’s behavior in a specific context. Thus, while the early steps given in the cases described above make reference to a learning history that bears a similarity to the medical model, these steps are not particularly important to the outcome of treatment. The treatment doesn’t depend upon the client understanding his or her history. Although helpful in giving the client a basis for understanding how his or her problem may have come about and why the treatment approach makes sense, there is no implication that having [insight] into these factors is necessary or useful as a remedy. (p.111)

セリグマンの学習性無力感理論
Seligman’s learned helplessness theory is a cognitive theory in that it is rooted in an assumption about one’s futility to affect important future events. The cognitive theories of depression that have been most influential have been those of Ellis (1962) and Beck (Beck, Rush, Shaw, & Emery, 1979). Cognitive theories conceptualize depression as the result of the development of faulty perceptions and appraisals of events. Negative cognitions in the form of negative attitudes and negative selfstatements arise as the result of adopting negative beliefs that shape how views of the self, the world, and the future are organized. Beck refers to this as the [negative triad] (Beck, 1967). The cognitive features of low self-esteem, self-blame, a sense of deprivation, and feelings of being overwhelmed by responsibilities are derived from negative interpretations of events in the lives of people who develop depression. Beck’s theory also posits that individual differences in the reinforcement value associated with different kinds of life experiences are responsible for activating cognitive vulnerabilities for depression. Individuals for whom self-worth is tied more to social relationships are high in [sociotropy] and are particularly vulnerable to social losses; those for whom independence and achievement are more highly reinforcing—that is, high in [autonomy”—are more vulnerable to the experience of failure or threats to their control. (p.119)

行動活性化(behavioral activation)も有効な行動療法です。
Taking the work of Ferster a step beyond a behavioral explanation for depression, Peter Lewinsohn developed a system for applying the behavioral principles to clinical settings in the treatment of depression. His method for treating depression was called behavioral activation. Because depression often results from low levels of positive reinforcement and high levels of punishment, Lewinsohn and colleagues (Lewinsohn, 1974) sought to increase positive reinforcement in peoples’ lives through behavioral activation. They developed an instrument called the Pleasant Events Schedule (MacPhillamy & Lewinsohn, 1972, 1982) that consisted of a long list of reinforcing events—also referred to as [pleasant events]—to measure the presence or absence of such events in peoples’ lives. The goal of behavioral activation for depression at this time was to help clients schedule pleasant events into their weeks. The more pleasant events the depressed client scheduled and engaged in, the more reinforcing life would become. As the negative experiences decreased and reinforcing experiences increased, there was a decrease in depression. Like other behavioral models, Lewinsohn’s approach proposed that clients engage in activities that were counter to depressive and punishing activities. It is rare for a person to be engaged in a pleasant activity and feel depressed, just as it is difficult to be relaxed and anxious at the same time, which you will recall was the theory behind systematic desensitization, one of the earliest behavior therapies. (p.124)

行動療法の中で行動そのものよりも認知のゆがみの改善を重視するのが認知行動療法(cognitive-behavior therapy)です。
there is good reason to believe, based on the results of a host of experiments done in the behavioral frameworks described above, that reinforcement principles are basic to the problem, that cognitive elements are very important to an understanding of how the depression is expressed, and that addressing avoidance behavior is central to the remedy. (p.120)

A widely practiced branch of behavior therapy is cognitive-behavior therapy. Its basic assumption is that core irrational ideas are at the root of mental disorder. When applied to depression, negative cognitions are assumed to influence the onset and course of depression, and the remedy for the disorder is believed to depend upon a change in these cognitions. Within this framework, what is emphasized is the manner in which humans characteristically process and organize information about experience into belief systems, expectations, and attributions that form the basis for how we interpret what is meaningful in our life. These processes are assumed to be adaptive. Depression, however, is viewed as the outcome of cognitive distortions within this system. It is the outcome of negative beliefs, particularly having to do with a sense of inadequacy, views of others as uncaring, hopelessness about the future, and the conviction of an absence of control over one’s life. The goal of cognitive-behavioral therapy is the replacement of these negative perceptions and beliefs with more adaptive ones. Behavioral and cognitive techniques are relied upon to accomplish this goal. Therapists engage in a dialogue with clients with the goal of identifying dysfunctional beliefs and other self-defeating ideas. They assign behavioral experiments to test the validity of beliefs, and behavior therapists assist clients in direct behavior change practices. (p.100)

The most important components of cognitive therapy are the modification of dysfunctional thoughts. Beck and his colleagues identified three types of thoughts: automatic thoughts that are situation specific—a letter from your mother arrives in the mail and you think [oh, no, bad news is on the way;] underlying assumptions and conditional beliefs that arise in multiple situations such as [I should always be a kind person] or [if I am nice to everyone, people will like me;] and core beliefs that are proposed to be enduring, cross-situational, and absolutist beliefs about the self and the world such as [I am incompetent.] Cognitive-behavioral approaches to therapy aim to identify and correct these assumptions and beliefs that trigger negative emotions and interfere with constructive behavior. (p.125)

認知行動療法が薬物治療より効果的であることはすでに証明されています。
Many studies support the use of cognitive-behavior therapy with depressed clients. The treatment usually outperforms pill placebo or waiting-list control groups. Cognitive-behavioral therapy is considered an empirically supported treatment by the American Psychological Association’s Division of Clinical Psychology (Division 12) that requires such treatments to be supported by research at multiple locations and replicated in multiple studies (Chambless et al., 1998). Therapists with more experience and training have been shown to have superior success (DeRubeis et al., 2005). Although antidepressant medication may work faster and initially demonstrate slightly superior outcomes to cognitive-behavior therapy (DeRubeis et al., 2005), both treatments are useful with moderately to severely depressed clients, contrary to popular medical treatment guidelines suggesting that medication should be the first choice with moderately to severely depressed clients. Furthermore, in a 12-month follow-up to a comparison study between cognitive therapy and paroxetine (Paxil), only 30.8 percent of the cognitive therapy patients relapsed after treatment was ended, whereas 76.2 percent of clients originally treated with paroxetine relapsed once the medication was discontinued (Hollon et al., 2005). This suggests that cognitive therapy has a more enduring effect than antidepressant medication. (pp.125-6)

While behavioral approaches to therapy continued to be popular among academic, research-oriented psychologists, many practicing clinicians were strongly influenced by cognitive therapy during the 1980s. Because cognitive therapies also make use of such behavioral techniques as activity scheduling, relaxation training, and social skills training in conjunction with the modification of beliefs, the technique came to be known as cognitive-behavior therapy (CBT). CBT is now one of the most widely studied treatment approaches for a variety of problems ranging from depression to obsessive-compulsive disorder. Furthermore, it is one of the few therapies that has consistently performed as well as, or outperformed, medication in the treatment of depression in a number of controlled clinical trials. (pp.126-7)

In summarizing the efficacy research on CBT for depression, Craighead, Craighead, and Ilardi (1998, p. 229) state that:
With the possible exception of [one major study—discussed below],
the essential finding in all these studies is that CBT is equally effective
to antidepressant medication in alleviating [major depressive disorder]
among outpatients … Typically, 50—70% of (these) patients who com-
plete a course of CBT no longer meet the criteria for (major depressive
disorder) at posttreatment.
(p.127)

11月 8, 2014 · Pukuro · No Comments
Posted in: ☆医療系

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