Efficacy of Treatment Approaches in Outpatient Therapy - Research Paper Example

EFFICACY OF TREATMENT APPROACHES IN OUT-PATIENT THERAPY Anti-depressant medications have been considered as the best outpatient treatment for most depressive disorders, despite the fact that reviews and evidence suggesting otherwise that evidence-based psychotherapies are just as effective as pharmacotherapy when it comes to treating major depressive disorders. This study makes the case for the efficiency of CT and REBT for outpatient therapy. It specifically shows that cognitive therapy is more effective than pharmacotherapy, for outpatient therapy, regardless of how severe a patient’s depression is. It also finds that REBT is not only efficient and useful in a wide range of outpatient clinical outcomes and clinical diagnosis, but, it is also efficient for non-clinical as well as clinical therapy, for both males and females. It thus, persuades policy makers to adopt and enforce the use of evidence-based psychotherapies such as CT and REBT as primary approaches to outpatient treatment of major depressive disorder. Efficacy of Treatment Approaches in Out-Patient Therapy Introduction For a long time anti-depressant medications have been considered as the best outpatient treatment for most depressive disorders, despite the fact that reviews and evidence suggesting otherwise that evidence-based psychotherapies are just as effective as pharmacotherapy when it comes to treating major depressive disorders. This, may be as a result of numerous assumptions made which have tended to support the claim that antidepressant medications do not only cost less, but are also more effective, when compared to psychotherapy. Psychotherapies are considered to cost more since their costs are measured based on the duration of therapy sessions as well as follow-up visits, something that most researchers, for instance, Cuijpers et al., (2013) and Gaskin (2012) have argued may possibly last throughout the lifetime of a patient. This need not to be the case; in fact, arguing efficiency of psychotherapy based on costs may be inaccurate given that costs will be based on the costs of therapists time relative to therapeutic drugs. In fact, most researches that attempt to compare the effectiveness and costs of different pharmacotherapies, as well as those that attempt to review costs psychotherapies against pharmacotherapies, most likely report conflicted results and findings. For instance, Cuijpers et al., (2013) and Gaskin (2012) reported that interpersonal psychotherapy and cognitive-behavioral therapy were both costly but more effective compared to a myriad of usual care and control interventions. However, David, Szentagotai, Lupu, & Cosman, (2008) later asserted that both psychotherapies and pharmacotherapies have similar effectiveness when it comes to outpatient treatment of depression. According to Ellis (1997), the effectiveness of pharmacotherapies and psychotherapies are sufficiently similar, when the focus is on exclusively examining the cost-effectiveness on the potential cost differences. Pharmacotherapies, apparently, result in 23% higher costs compared to psychotherapies such h group and individual cognitive-behavior therapy; in fact, group CBT, according to Sava, Yates, Lupu, Szentagotai, & David (2009), results in up to 2% savings in costs. This paper, therefore, attempts to defend the efficacy, cost-effectiveness and cost of psychotherapies, particularly of Cognitive Behavioral Therapy, CBT, specifically CT-Cognitive Therapy, and REBT-Rational Emotive Behavioral Therapy, with regards to outpatient treatment of depression. CT, Cognitive Therapy, which is a form of Cognitive Behavioral Therapy, is chosen because it is one of the most widely used psychotherapy techniques with a considerable evidence base. It includes and entails dysfunctional thought modification and behavioral activation, in addition to structural modification and identification of generalized core beliefs which are considered to be the chief causes of dysfunctional thinking and depressive reactions and behavior. REBT-Rational Emotive Behavioral Therapy, another form of CBT, is chosen and defended because it is considered to be focused on various cognitive processes (Ellis, 1997). Additionally, evidence of its effectiveness is also accumulating as suggested by (David et al., 2008). REBT-Rational Emotive Behavior Therapy, most importantly attempts to alter the cognitive process by explicitly focusing on reducing or even eliminating secondary problems including depression about depression; by supporting unconditional acceptance of self (Mischel, 2004); by emphasizing on the major causes of negative feelings such as irrational beliefs; and by focusing and emphasizing on demandingness, which, according to Ellis (1997), is the major belief involved in major depressive disorders. Discussion Cognitive Therapy Cognitive therapy for the treatment of depressive disorders has its roots in the theory of cognitive depression devised in 1967 by Becks (Burger, 2011). It refers to a structured, active, time-limited, and problem-based approach to treatment of depressive disorder, which relies on the foundation that depression is anchored and maintained by negatively biased dysfunctional beliefs and information processing. Cognitive Therapy, CT, is designed to assist patients so learn how to think in a more adaptive way, and thus experience improvements in motivation, behavior and in affect. More than thirty clinical trials have been conducted to demonstrate the effectiveness of CT-Cognitive Therapy. The most used approach for cognitive therapy for treating depression generally entails guiding and helping patients through a myriad of structured learning experiences. Depressive disorder patients are taught to observe and write down their negative mental images and thought, and to identify the relationship between their feeling, thoughts, behavior and psychology. Patients learn how to evaluate and examine the utility and validity of these cognitions; they are able to empirically test them out, and alter dysfunctional cognitions in order to reflect a more adaptive perspective (Butler & Beck, 1995). With the progression of the therapy, patients learn to recognize, modify, and examine underlying dysfunctional beliefs and assumptions that may have subjected them depressive reactions and behaviors. Through cognitive therapy, therapist are also able to teach and reactivate the patient’s adaptive coping skills such as being able to breakdown large problems in more manageable, smaller, steps, and decision making via cost-benefit analysis. Self-monitoring of pleasure and mastery, activity scheduling, as well as graded task assignments are the most used, especially early on in the therapy. They help patients expose themselves to possibly rewarding experiences, as well as overcome inertia (Beck, 1995). This therapy technique follows a session-based structure, which includes a brief check on symptoms and mood, setting the agenda, and bridging the session with the last session, discussion issues on the set agenda, and reviewing self-help assignments done by patients between sessions, setting new how assignments, getting and summarizing feedback received from the patient regarding the session (Beck, 1995). It is important to note that, cognitive therapists apply a myriad of techniques and strategies to assist depressed patients address their thought including guided discovery, psycho-education, role playing, behavioral experiments, Socratic questioning, and imagery. In order to gain a reasonable mastery level, patients usually need close to eight sessions with the skills and model involved. During this initial therapy stage, David et al., (2008), asserts that there is a significant reduction in patient’s depressive disorder symptoms. The rest of the sessions are usually utilized in examining and modifying a patient’s dysfunctional beliefs, which impair their normal functioning and makes them more susceptible to future depressive episodes. Additionally, it helps patient develop skills to prevent relapse, as well as discuss issues related to termination. Within 8 and 12 sessions, David et al (2008) and Sava et al.,(2009) argues that most patients show a reduction of symptoms. A complete cognitive therapy treatment is believed to take between 14 and 16 sessions, severe cases, however, may take longer than that. Occasional booster sessions are also used, especially during the initial year of termination, to enhance maintenance of treatment. As had already been mentioned, the efficiency of cognitive therapy for outpatient treatment of depressive disorders has been extensively studied; in fact, studies such as those by David et al., (2008); Gaskin, (2012); McClain & Abramson, (1995); and Sava et al., (2009) have found and concluded that cognitive therapy CT is superior and effective when compared to other alternative outpatient therapy interventions. An evidenced based study by Dobson (1989), which was based on BDI, Becks, Depression Inventory scores at the end of 28 controlled treatment , showed that using cognitive therapy for outpatient depressive disorder therapy was much superior and effective compared to pharmacotherapy, a wait list condition, behavior therapy, as well as other psychotherapies (Dobson, 1989). Studies such as that by Gaskin (2012) and that by Sava et al., (2009), which compared the cost-effectiveness and efficacy of cognitive therapy for depressive disorders with pharmacotherapy, specifically showed and concluded that that cognitive therapy was more effective than pharmacotherapy regardless of how severe the depression was. In fact, follow-up studies of the patients that were treated using cognitive therapy in major controlled treatment trials opined that cognitive therapy was more effective, especially with regards to relapse prevention compared to pharmacotherapy alone. Patients treated using cognitive therapy were just half likely to seek further treatment or relapse following the end of their treatment, than those patients that were treated using pharmacotherapy alone (Sava et al., 2009). Rational Emotive Behavior Therapy (ERBT) Rational Emotive Behavior Therapy (ERBT) is a Cognitive Behavioral Therapy approach which was started by Albert Ellis. It is a therapy approach, which is focused and emphasizes on the active present approach to problem solving. Rational Emotive Behavior Therapy considers that people are responsible of their own emotions and actions. Further, it also considers the harmful behaviors and emotions that people have are as a result of their own irrational thinking. Rational Emotive Behavior Therapy considers human beings as being capable of learning more new realistic ideas, as well as practicing them in their lives. Finally, Rational Emotive Behavior Therapy holds the view that if persons are able to develop a more adaptive viewpoint based on reality as opposed to having irrational perspectives; they will have greater satisfaction as a result of their own acceptance. Ellis (1997) considers twelve irrational ideas, however, he concedes that they are only three; he asserts that Rational Emotive Behavior Therapy assumes that human action, emotion, and thinking are not just disparate or separate process, but they all significantly overlap; they are rarely experienced in a clean state. Most of what is considered by humans as emotion is just but a certain kind of a prejudiced, intensely evaluative, and biased kind of thought. Behavior or emotions, however, greatly affect and influence thinking. Being strongly evaluative is an integral attribute of human beings; it works in a somewhat closed circuit with a feedback contrivance, since response is biased by perception and that perception subsequent response. In fact, subsequent perceptions are somewhat biased by prior perceptions, while subsequent responses are biased by prior responses. One Rational Emotive Behavior Therapy techniques considers people to take responsibility of their own actions; ones reactions to certain events re likely to upset them, but events alone cannot upset them. People create their own reality by how they often times react to events in their own lives. Rational Emotive Behavior Therapy also involves the identification and recognition of how people affect their own welfare, identifying things referred to as musts; they include demand on oneself, demand on others, and demand on situations. Rational Emotive Behavior Therapy believes that people can only solve their own bad feelings by considering which of the musts, the irrational beliefs, that people make themselves unhappy. People must be able to disapprove their own musts by realizing that they are in fact irrational beliefs. The musts must be rephrased to contain acceptance and love. Thus, Ellis attempts to assert that no matter what a patient or person has experienced and done, they must always learn to accept themselves for what they are, and not what they have not or have accomplished in life. Rational Emotive Behavior Therapy begins with the patient guided into identifying a problem, as well as what the patient feels about it. The patient is then guided to devise an irrational belief about the said problem and comprehending why he or she thinks it is irrational. Then, the patient disputes the irrational belief, by discovering and identifying reasons why the belief is considered irrational. Rational Emotive Behavior Therapy requires the patient to come up with more accepting and acceptable belief, and recognize how to avoid relapse, as well as obstacles to the progress of him or her changing his or her beliefs. Rational Emotive Behavior Therapy REBT is more effective for outpatient therapy since the therapist assumes a more proactive role as opposed to other approaches. In fact, in Rational Emotive Behavior Therapy, therapist can dispute the patient’s belief, push him or her to challenge him or herself, as well as assign the patient some homework. Rational Emotive Behavior Therapy REBT is also considered effective for outpatient therapy because it utilizes visual imagery to get patients to visualize times or moments in their lives when they had a certain feeling, and recollect what and how it felt to have that feeling; this thus helps them dispute that irrational and emotional belief. Even long after the termination of the therapy, the patient can still use the imager as a toll to retain his or her thinking with regards to a myriad of events that took place in their life. This approach is also unique in the sense that the therapist is not there to be nurturing and warm to the patient, but rather, is there to assist the patient identify his or her irrational beliefs or musts. According to Ellis (1997), continuous evaluation of one’s life often leads to unhappiness; thus therapy needs to be approached in a way that avoids or stops patients from doing that. This according to David et al. (2008) explains why Rational Emotive Behavior Therapy is effective for outpatient therapy since it leads patient’s to simple acceptance; it grants patients the courage and strength to change the things that they can, the serenity and tranquility to accept those things they cannot alter, and the wisdom and understanding to know the difference between the rational and the irrational. Rational Emotive Behavior Therapy being a proactive approach, it require patient to be willing to take responsibility for their actions and beliefs, and be ready to accept and change them. Most importantly, the effectiveness of Rational Emotive Behavior Therapy for outpatient therapy is pegged on the fact that it is a drug-free approach; especially, it is ideal for people that are interested in solution for altering the way that they think, without using any pharmacotherapy techniques. Further, the results for Rational Emotive Behavior Therapy are relatively quick since this approach emphasizes and focuses on the present. David et al. (2008) argues that its especially effective for outpatient therapy in which patients are adolescents or teenagers, since it does not, the therapist does not focus more on the bad things that have happened to the patient; rather, the therapist looks at a few activating situations and help the patient exercise on how to change his/her thinking regarding such situations or event. Various studies including that of David et al. (2008), which have attempted to determine and defend the efficiency of REBT have concluded that REBT is not only efficient and useful in a wide range of outpatient clinical outcomes and clinical diagnosis, but, it is also efficient for non-clinical as well as clinical therapy, for both males and females. Conclusion This study has managed to make the case for the efficiency of CT and REBT for outpatient therapy. It has specifically shown that that cognitive therapy is more effective than pharmacotherapy, for outpatient therapy, regardless of how severe a patient’s depression is. Further, it has found that patients that were treated using cognitive therapy in major controlled treatment trials opined that cognitive therapy was more effective, especially with regards to relapse prevention compared to pharmacotherapy alone. With regards to REBT, this paper found that REBT is not only efficient and useful in a wide range of outpatient clinical outcomes and clinical diagnosis, but, it is also efficient for non-clinical as well as clinical therapy, for both males and females. Thus, this paper persuades policy makers to adopt and enforce the use of evidence-based psychotherapies such as CT and REBT as primary approaches to outpatient treatment of major depressive disorder. However, it concedes that this decision may require more studies that will not only demonstrate efficacy, but also show the cost-utility and cost-effectiveness of these therapies. References Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. Burger, J. (2011). Personality (8th ed.). Belmont, CA: Wadsworth, Cengage Learning. Butler, A. C., & Beck, A. T. (1995). Cognitive therapy for depression. The Clinical Psychologist, 48(3), 3–5. Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. 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(1995). Self-schemas, stress, and depressed mood in college students. Cognitive Therapy and Research, 19(4), 419–432. Mischel, W. (2004). Towards an Integrative Science of the Person. Annual Review of Psychology, 55(1), 1–22. Sava, F. A., Yates, B. T., Lupu, V., Szentagotai, A., & David, D. (2009). Cost-Effectiveness and Cost-Utility of Cognitive Therapy, Rational E motive Behavioral Therapy, and Fluoxetine (Prozac) in Treating Depression: A Randomized Clinical Trial. Journal of Clinical Psychology, 36(1), 36–52. Read More