Beck Depression Scale - Essay Example

Assessment is an integral part of the therapy process. Without assessment, therapy would be aimless and, most likely, would not ultimately help the client in any significant way. For a one on one therapy session, the therapist obtain assessment information from the client before formulating a therapy plan; however this job is more complicated for the Marriage Family Therapist (MFT). The MFT must not only assess each member of the family, but also the family as a whole. There are a few goals of assessment for the MFT. One is to identify the key issues and concerns of the family. Assessment is also used to differentiate between how the individual members of the family perceive the family problems. One final goal of assessment is to get a clear understanding of the structure and functioning of the family. The MFT has specific information that he is looking to obtain during the assessment process. First and foremost, the MFT wants to gather as much information as possible on the problem the family is faced with. This includes the length of the current problem, the family's history of conflict, the family's history of solutions, and the family's motivation to rectify the current problem. The MFT also wants information about the structure of the family, such as any cultural or religious influences, socioeconomic status, and the hierarchy of the family. At the same time, the MFT wants to understand how the family functions; their conflict resolution strategies, how well they communicate with one another, each member's role in the family, and individual and collective goals. Finally, the MFT is interested in finding out what the family's goals are for therapy. There are many different ways in which the MFT can gather this assessment information, but they all fall into two broad categories: qualitative and quantitative. Qualitative assessment allows the therapist to make inferences about certain behaviors and reactions of family members during an assessment task, whereas quantitative assessment is in the form of a standardized instrument, usually a pencil-and-paper questionnaire or scale. There are many advantages of using qualitative assessments. The family plays a larger, more important role in the assessment process, the assessment becomes part of the treatment process since this type of assessment tends to be therapeutic in and of itself, the therapist can pick and choose different techinques that fit nicely with his specific theoretical orientation, it allows the therapist and family to work together in assessing the information obtained, the family is often more committed to therapy because of the vital role they play in the assessment process, individual family members learn from one another and can learn how each member is affected by the family as a whole, allows the family to be viewed in a three-dimensional context, and it can be used with families from various cultural, ethnic, and religious backgrounds (Deacon & Piercy, 2001). There are many qualitative techniques available for the MFT. Qualitative assessments include the use of art, guided imagery, photographs, role playing, sculptures, free association, metaphors, and circular questioning. The idea behind this type of assessment is that it takes the focus off of the individual, and places it on the task at hand, often making the clients less defensive and more emotive (Deacon &Piercy, 2001). While there are many advantages to qualitative assessment, it is not for everyone. Some therapists and clients may not feel comfortable with such exercises, and these exercises may in fact exacerbate any anxiety felt towards therapy instead of relieving it (Deacon & Piercy, 2001). In such a case, these exercises should not be pushed. If these activities are forced, the information gathered will most likely be scarce. Deacon and Piercy also note that while qualitative assessments can provide the therapist with a wealth of information, it cannot provide certain information that can only be obtained through quantitative assessment and therefore should be used in conjunction, and not instead of, quantitative assessments (2001). Quantitative assessment methods are much more impersonal and much less "hands on" that qualitative assessments methods, but they can provide the therapist with some important information. Quantitative assessment methods allow the therapist to obtain a large amount of information in a short amount of time, are backed up by research, allow for the comparison of the client to a normative sample, and can be given at intervals throughout therapy to track progress and change (Rowden, Harris, & Stahmann, 2006). Methods for quantitative assessment for use by MFTs are fairly new, however some do exist (Deacon & Piercy, 2001). One example of a quantitative assessment for the family is the Family Assessment Device (FAD). This instrument measures family functioning in the following areas: problem-solving, communication, roles, emotional response, emotional involvement, behavior control, and general functioning (Werner-Wilson & Arbel, 2000). Each member in the family is given this test and the score is compared to the other members in his family as well as what is considered to be a "normal" score. Another example of a quantitative assessment for use by the MFT is the Parent and Peer Inventory Scale (PPI). This scale covers four domains: general values and beliefs, dating and sexuality, alcohol and drug use, and political beliefs (Werner-Wilson & Arbel, 2000). In assessment, this tool can be used to understand where influence is coming from in a child's life, it can pave the way for a discussion about peer influence, it can show parents that it is "normal" for peers to influence superficial characteristics while parents influence more concrete values and beliefs, and can tell the therapist to look at different aspects of family functioning that can be changed to lower peer influence and raise parental influence in the case of a high PPI score (Werner-Wilson & Arbel, 2000). At the same time, MFTs may also turn to individual assessment methods. While these methods may not be created with the family in mind, they can still provide the MFT with valuable information about the members of the family. One such individual instrument is the Beck Depression Inventory (BDI). This instrument is a 21-item self-report questionnaire which assesses whether or not the client possesses depressive symptoms, and the severity of these symptoms (see appendix). This instrument may be given to each member of the family, or only one or two. In either case, the BDI is a very valuable tool for the MFT because of the negative impacts that depression has not only on the depressed patient, but also on the non-depressed members of the family (Brent et al., 1997). While these assessments cannot point to a specific form of treatment all by themselves, the MFT can turn to research in which these instruments were used to decipher which treatments worked to improve the measured aspect of functioning in the research sample. For example, if the MFT administers the BDI and determines that depressive symptoms exist, she may then turn to research as part of her assessment to find which treatments were found to lower BDI scores, and therefore lower depression. One specific example of such research compared the effects of therapy on different types of patients (Renaud et al., 1998). Subjects were between thirteen and eighteen years old; met the DSM-III-R criteria for major depression; had an initial BDI score of more than thirteen; and did not have a comorbidity of OCD, BPD, ED, psychosis, or substance abuse. Subjects were assessed prior to treatment, at the sixth session, and after the termination of treatment with various assessment methods. The BDI was also administered at each session. At the second session, the subjects were broken into three separate groups with regards to BDI scores: rapid responders, intermediate responders, and initial nonresponders. Rapid responders were defined as subjects whose BDI score decreased at least fifty percent from pretreatment to the beginning of the second session. Intermediate responders were defined as subjects whose BDI scores decreased more than zero percent but less than fifty percent from pretreatment to the beginning of the second session. Initial nonresponders were defined as subjects whose BDI scores remained the same or increased from pretreatment to the beginning of the second session. Renaud et al. found that rapid responders had a lower initial BDI than intermediate responders and initial nonresponders, and intermediate responders had a lower initial BDI than initial nonresponders. At the end of treatment, clinical remission, which was defined as no longer meeting the criteria for major depression and a BDI of less than nine for at least three consecutive sessions, was diagnosed. Rapid responders had a higher incidence of clinical remission than intermediate responders and initial nonresponders, while intermediate responders showed greater clinical remission rates than initial nonresponders. Follow-ups were also conducted one year after treatment and two years after treatment and were compared to the outcomes at the end of treatment. During these follow-ups, clinical recovery, which was defined as no longer meeting the criteria for major depression and a BDI of less than nine, was diagnosed. At the one-year follow-up, rapid responders showed a greater incidence of clinical recovery than intermediate responders and initial nonresponders. At the two-year follow-up, there was no significant difference between these three groups in regards to clinical recovery. Renaud et al. concluded that short therapies are sufficient for mildly depressed patients, while longer, more specialized types of therapy are necessary for patients with severe depression (1998). Another example of research compared the effects of cognitive, family, and supportive therapies on depressed adolescent patients (Brent et al., 1997). Subjects for this study were between thirteen and eighteen years old, were living with at least one parent, met the DSM-III-R criteria for major depressive disorder (MDD), and had an initial BDI of thirteen or higher. Subjects attended twelve to sixteen weekly sessions and were randomly assigned to cognitive-behavioral therapy (CBT), systemic family behavior therapy (SBFT), or nondirective supportive therapy (NST). CBT focuses on the ability of the client to change and control negative thoughts and beliefs. In SBFT, the therapist identifies dysfunctional family patterns and works with the family to make it more functional throught the acquisition of problem-solving and communication skills. The focus of NST is to "establish, maintain, and build rapport, provide support, and aid the patient in affect identification and expression of feelings through reflective listening, provision of accurate empathy, and discussion of patient-initiated options for addressing personal problems" (p. 878-9). The NST therapist does not give advice or teach skills. Brent et al. (1997) found that those in the CBT group had a quicker relief of MDD symptoms than those in both the SBFT and NST groups. Also, a greater percentage of CBT subjects displayed clinical response, which was defined as a BDI of less than nine for at least three sessions in a row and maintained until the termination of treatment, than did subjects in SBFT groups. They also found that a greater percentage of CBT subjects displayed remission, which was defined as a BDI of less than nine and the inability to meet DSM-III-R criteria for MDD, than subjects in both SBFT and NST groups. Brent et al. concluded that CBT was significantly more effective in treating adolescents with depression than NST or SBFT. One final example of relevant research showed the relationship between negative thoughts, dysfunctional beliefs, and depression (Kwon & Oei, 2003). This study tried to distinguish whether the negative thoughts that are targeted in CBT cause depression, or whether depression causes negative thoughts. Subjects attended two-hour weekly sessions for twelve weeks. During the first four weeks, subjects and therapists worked together to identify and correct the subject's negative thoughts. During the next four weeks, subjects and therapists worked together to identify the dysfunctional beliefs that underlie the subject's negative thoughts. During the last four weeks, the therapists taught the subjects skills that could be used to continue to make progress toward eliminating negative thoughts and dysfunctional beliefs. Kwon & Oei (2003) used the BDI to measure depressive symptoms, the Automatic Thoughts Questionnaire (ATQ) to measure negative thoughts, and the Dysfunctional Attitude Scale (DAS) to measure dysfunctional beliefs. These measures were taken prior to treatment, at the fourth session, at the eighth session, and after the termination of treatment. It was found that the prevalence of depressive symptoms were significantly lower at each testing interval when compared to the prevalence of depressive symptoms at the testing interval immediate prior. It was also found that the prevalence of negative thoughts was significantly lower at the fourth session when compared to the prevalence of negative thoughts prior to treatment. With regards to dysfunctional beliefs, it was found that their prevalence was significantly lower at the fourth session when compared to their prevalence prior to treatment, and their prevalence was significantly lower at the eighth session when compared to their prevalence at the fourth session. All of these findings taken together suggest that lowering the level of negative thoughts leads to a lower level of dysfunctional beliefs which leads to a lessening of depressive symptoms. Given these three examples of research, the therapist in the hypothetical situation stated above can now begin to formulate a therapy plan. According to the research, the best form of therapy for the depressed patient would be some form of CBT. It is important to note, however, that these examples are only a small glimpse at the large amount of research available on therapy for depressed patients. Any therapist, including MFTs, would be aware of the current research in the field, and would try to get a better understanding of the therapy options available. At the same time, it is also important to remember that results obtained in a research setting do not always neatly carry over into the therapy setting. Because the research setting is a much more controlled environment, the therapist should be open to the possibility of different results than those obtained in research. The example outlined above showed how the MFT can use research during assessment to formulate a therapy plan to treat an existing problem, however the MFT can also use research during assessment to formulate a therapy plan to prevent a potential problem. For example, if the MFT is treating the family of a developmentally delayed child, she can turn to research to formulate a therapy plan to prevent depressive symptoms in these parents. Kker (2005) proposed that early intervention programs can work to decrease and prevent high levels of stress and depression in parents of delayed children. While parenthood in general tends to come with its fair share of stress, parenting a developmentally delayed child can increase this stress. There are many factors which may contribute to this increase in stress, including "extra child-care responsibilities, difficulties to meet the demands of other family members, lack of knowledge about the child's disability, limited opportunities for appropriate treatment and/or educational services andits burden on the family's financial resourcesdifficulties to cope with the negative attitudes of the community and worries about the future well-being of the child (Kker, 2005, p. 329-330). Kker (2005) studied mothers and fathers enrolled in the Small Steps Early Intervention Program (SSEIP). This program was an eight month, home based program which focused on teaching parents the necessary skills to care for and nurture developmentally delayed children. In addition to the home training that these parents received, they also attended monthly meetings with therapists and other parents of developmentally delayed children. During these meetings, parents were encouraged to share their feelings and experiences associated with the program and their children in general. Kker found that when comparing BDI scores taken prior to the program and after the termination of the program, depressive symptoms were significantly lower for mothers and fathers after the termination of treatment. In the hypothetical therapy situation given above, this research would be very helpful for the MFT during the assessment process. This is only one example of the use of quantitative assessment measures used in research to create a therapy plan for prevention of a problem. Once again, as with using research to create a therapy plan for treatment of a problem, the therapist must be aware of the possible complications of trying to carry a treatment used in an experimental setting over into a clinical setting. Assessment is a key component to any therapy process. Without it, the therapist is likely to waste her valuable time, along with the client's money. Assessment guides the therapist in the therapeutic direction best suited for the client, allows the therapist to better know the client, and can be used as a method to track progress and change during the therapy process. Assessment can take on many forms, whether it be the more standardized methods of quantitative assessments or the more creative, insightful methods of qualitative assessments. Because both methods have their advantages and disadvantages, it is important to use both, if possible, during the assessment process in order to get the best picture of the client and gather the most information possible. At the same time, assessment does not necessarily end when the client leaves, since research can be a very helpful tool in the assessment process. When the MFT uses these methods in conjunction, she can be sure that she is formulating the best therapy plan possible. Appendix References Brent, D. A., Holder, D., Kolko, D., Birmaher, B., Baugher, M., et al. (1997). A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychology, 54(9), 877-885. Deacon, S. A., & Piercy, F. P. (2001). Qualitative methods in family evaluation: Creative assessment techniques. The American Journal of Family Therapy, 29, 355-373. Kker, S. (2005). The family-focused early intervention programme: Evaluation of parental stress and depression. Early Child Development and Care, 176(3), 329- 341. Kwon, S., & Oei, T. P. S. (2003). Cognitive change processes in a group cognitive behavior therapy of depression. Journal of Behavior Therapy and Experimental Psychiatry, 34, 73-85. Renaud, J., Brent, D. A., Baugher, M., Birmaher, B., Kolko, D. J., et al. (1998). Rapid response to psychosocial treatment for adolescent depression: A two-year follow- up. Journal of American Academy of Child and Adolescent Psychiatry, 37(11), 1184-1187. Rowden, T. J., Harris, S. M., & Stahmann, R. F. (2006). Group premarital counseling using a premarital assessment questionnaire: Evaluation from group leaders. The American Journal of Family Therapy, 34, 47-61. Werner-Wilson, R. J., & Arbel, O. (2000). Assessment of interpersonal influences of adolescents: The parent and peer influence scale. The American Journal of Family Therapy, 28, 265-274. Read More