In the second part of this episode with Professor Steve Hollon, we go beyond theory into the heart of applying cognitive therapy for depression in real-world settings. Steve shares what therapy really looks like across the spectrum from relatively straightforward to deeply complex clients and how therapists can stay grounded and effective, even when things feel messy.

Resources and links

Cognitive Therapy of Depression (Second Edition)

Find out more about Steve and his research here

OXCADAT:

A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/

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This podcast was edited by Steph Curnow

Transcript:

Rachel Handley:  Welcome to Let's talk about CBT- Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients.

Welcome back to part two of our conversation with Professor Steve Holland, international expert in cognitive therapy of depression. In our last episode, Steve gave us some fascinating insights into the development of the cognitive model and how we can understand the development and maintenance of depression.

In this episode, Steve talks in detail and with lots of examples about how to apply the therapy to really help people with all sorts of complexity in their lives without fear of getting it wrong. So let's dive straight in.

Rachel Handley: And so, if you had to put in a sentence the main task of therapy, and I know asking any researcher to put anything into one sentence is a challenge, right? But what would you say is the purpose of therapy that we need to keep foremost in our minds to guide therapy?

Steven Hollon: I'll say two things if I can

Rachel Handley: I'll allow you two.

Steven Hollon: Then I'll say two things. The first component is, when in doubt, do. If you're depressed, don't wait to feel like doing something. You're not going to feel like doing anything. Do the stuff you would do if you weren't depressed.

And then the desire will come back, but don't wait to feel like it. And the second thing is don't believe everything you think. And the most powerful way to disconfirm an existing belief is to test it in a situation that your therapist can't control. Therapists get paid to tell people they're okay, or in some cases, dynamic, tell people they're not okay and if you've got kids to put through college, that's a nice, long term life lifestyle. But, what I'll do with the client when we start out and I learned to do this with Tim Beck and Maria Kovacs and others is in the very first session say, look, we can do this a couple of ways. There's some things I'd like to teach you how to do. And I can either do them for you or I can teach you how to do them. My goal is to make myself obsolete. Is that okay with you? And usually then people say, yeah, I’d prefer that. Usually, occasionally they won't, but usually they'll say that. And I’d say, now, if we were going to help you learn how to do these things, how can we do that? Say, well, can I work on this stuff between sessions? That's a great idea! So let people reinvent the therapy each time coming through. Then you'll end the session and have something for them to do between this and the next session.

And by the way, every major study that has shown an efficacy for cognitive therapy has always seen people who are clinically depressed at least twice a week in the beginning. If I have to wait seven days to meet somebody, to work with somebody who's deeply depressed, they're going to forget who I am. I mean, their hippocampus is turned over. It's a, you have to reintroduce yourself. I get a little momentum going over that first session. Give me two or three days later I can keep the momentum going like Sisyphus pushing the rock up the hill. I don't know what things are like in the UK, but I would always want the depressed client to have twice weekly sessions in the beginning. It doesn’t have to be an office, one could be over the internet and then I'll space it out later on. Maybe we get a couple of weeks in, then we'll drop back to every other week.

Rachel Handley: And certainly that kind of frequency of therapy is one where we have fallen into habits of, the routine is once a week for an hour on the same day and not one that a one that services often struggle with implementing logistically in terms of this, but certainly, looking at the evidence and the good clinical practice, it seems to be a point that bears reiterating.

Steven Hollon: Its for the benefit of the convenience of the therapist, not for improving clients.

Rachel Handley: So in terms of therapy, then it's don't think about it, do it. And don't believe everything you think.

Steven Hollon: Well, yeah, in terms of the behavioural components, don't wait to feel like it. Do it. But when you do, do a test that tests your beliefs when you do it. With the sculptor, if you don't think anybody's going to hire you, then put applications in. Let's see if you're right. You might be, in which case work on a career change, but don’t your problem is right now not that you're incompetent. You might be. Well, we don't know that yet. What we do know is you're not sending out your portfolio and until you send your portfolio out, we don't know how competent you are. So let's find out.

Rachel Handley: So let's test the strategy. So keeping in mind that you've said in the manual, which is a brilliant revision, the second edition of Cognitive Therapy for Depression, that therapy is not just a set of strategies or techniques, however, it's helpful to know what a typical course of therapy might look like. Can you tell us what an episode of therapy might look like for someone coming in for cognitive therapy for depression

Steven Hollon: I mean, yeah, that’s a great question. I think it depends very much on what the client walks in the door with, like the sculptor, nothing much going else going on for him, except he had lost his job, probably no misfortune of his own, but he was going about getting the next job the wrong way. I mean, he was working, but something he didn't consider work and it was just a relatively simple matter of pitting his Theory A, which is I'm incompetent versus Theory B, which is he's going about it the wrong way, which is take a big task, break it into small steps, take it one step at a time, rather than getting overwhelmed with the magnitude of the task. Easy for him.

Another client that I talk about is a woman that came into one of our trials that Rob DeRubeis and I were doing, and she ended up drawing me as a therapist. She knew some of the graduate students already. She'd done her training at Vanderbilt several years earlier. And when she got back to town at this point, on the way to getting divorced, real things have blown up for her in her personal life. She's absolutely devastated. Gets back into town, talks to some of her graduate student colleagues, hears about this study, decides I'm going to be in that, goes on clinicaltrials.gov, looks up what the inclusion-exclusion criteria were, sees that we were referring out people with borderline because they could get DBT in Nashville, they're going to do better with that than with what we had to offer. She borrows a copy of DSM, looks up what criteria are for borderline, knows what to deny when she comes in for interview, gets screened into the trial, gets me as a therapist, to her misfortune. In the first session, I start the thing about saying what I prefer to do is teach you how to do this as opposed to simply do it for you. And she said no, you don't understand. I am flawed. I am deeply flawed. Something happened to me as a teenager. I don't want to talk about it. I don't think we need to, but it changed me forever. I tear up anybody I get close to. I would like to have relationships with people that I care about. But anybody I get romantically involved with, I just tear them to shreds. I become this dragon lady, tiger lady. And she said, no, don't worry about that cause I'm 29. I turn 30 in six months and I don't plan to live past 30. And the third thing she said was now I'm an incorrigible liar and you can't believe a word I say, will be a problem for therapy?

And of course it won't be, and it won't be a problem for therapy because no matter what story she makes up, it's going to have coherence. Evolution constrains that if she comes and tells a story about something that got her angry, then she's going to have cognitions that are consistent with somebody did something they shouldn't. The physiology is going to be aroused, and the behaviour is going to be want to attack, which is what she did in context of her relationships. So you can work with all that stuff. I never worked with somebody quite like her before, we were 3 years and in the beginning, because she was able to coerce me into it, we were meeting daily and we're meeting pretty much daily for the 1st year. And then we drop back to a couple of times a week in the 2nd year and then spaced out beyond that time. She made a marvellous return recovery, but it was slogging and I didn’t know what we were doing half the time, so we're making it up as we go along, more complicated minds are going to take longer.

Now, I know from some of the training with IAPT folks, they don't necessarily get longer. However, those folks are going to show up in the service again, as Marsha Linehan would say, you can either pay us now for DBT which is going to be a couple of years, or you can have them showing up in your emergency room, bleeding on the floor, you know, how you want to set up your systems? And what I'll encourage the folks in IAPT to do is, if you get what, 10, 12, session, however many sessions you get, go as far as you can go, but for goodness sake, lay out a cognitive conceptual diagram. So they have a roadmap. The next time they show up with a therapist, they can say, can we start here? I've covered all of this stuff. I'd like to pick up with you and, you know a new therapist, but we don't have to go through all the same ground, do we? I can show you this. I know how to do that.

Rachel Handley: And what would that cognitive conceptualist diagram look like?

Steven Hollon: Oh, yeah. For the sculptor, there wouldn't be much there. Just his dad used to favour his younger brother when he was younger, so he came to believe he was incompetent. And he did have a lot of other problems going on, just when he got in a tough situation, he would give up too soon. So instead of giving up, let's break it into smaller steps, make it easier to do. It's like walking up a hill. You're more likely to get up a hill if you have steps than if you have to go straight up the icy stream.

For the architect, gee, this terrible, awful thing, which no great mystery was involved a gang rape when she was about 15 and her father totally blew her off. She'd already lost her mother about six months earlier. She developed the belief that nobody could ever possibly love her or meet her halfway. So in a relationship, she developed a host of compensatory strategies, what people treating anxiety disorders would call safety behaviours. And her compensatory strategies, when she got close to somebody, she wouldn't ask for what she wanted because she would assume they would turn her down. She couldn't be very direct with somebody she was starting to get close to. And she would be provocative without meaning to be because if they didn't give her what she wanted, she would then act out. And, yeah, she stayed basically 15. And those strategies were the things that were screwing up a relationship one after the other, but she thought they were protecting her from being rejected. And they weren't, they were just the thing that was causing the rejection and until she started to test some of that out we- it was Anke who had to walk me through, it was my first time walking through the reliving of the traumatic experience and Anka had to give me some guidelines on how to do that. We did. It took me about an extra month to get around to doing it, three months to talk her into it, a month to talk me into doing it. My graduate students shamed me into doing it because of course they all learned how to do that in the sexual assault centres before they ever get their degrees. At any rate, it was revelatory. She not only had this notion that she was damaged property, that no decent male would ever want to have a relationship with the thing that happened to her. She also had this notion that, which she didn't have a clue about, which was that it was so scary to think that something so awful could have happened to somebody that didn't deserve it. She wanted to wrap herself up in this really tough, film noir model role. And that was the image of herself she presented the world. What she had to do is drop that stuff and get somebody she was really getting close to, have some night where she would let down the guard, tell them everything that happened to her and see what happened. She wasn't going to do that with the current boyfriend, but she would do that with me as a therapist. She would do that with an old girlfriend that she hadn't seen for years. She invited her up to have a long weekend in Nashville, pleasant, etc. And then she told the girlfriend about what had happened to her. The girlfriend commiserated for about 30 minutes and said, you want to get something to eat? The girlfriend didn't care. Took her a while longer. We had a couple of additional pieces of information she wanted collected by people other than me. And, so we ran some surveys and the like, tape recorded. And then it turns out most people, most eligible males wouldn't be the least bit concerned. One or two would, but she blew them off anyway. She's not ready to talk with the current boyfriend but has a revelatory experience, conversation with him. He commiserates for about 20 minutes. Males aren't as good at that as female friends and said, you wanna get something to eat? He didn't care. What he didn't like was when she picked on him when she was mercurial in the relationship. When if she wanted something instead of asking where he could either decide whether he would give it to her or not, she would try to manipulate him that he didn't appreciate. So when she got past that, she was able to start dropping the compensatory strategies which she thought was protective from being rejected, that's why she was getting rejected, but it took us a while to get there. Now, maybe, having had more experience with that, of the 10 patients I worked with in the Penn-Vandy trial, five of them had histories of sexual abuse, which I do think is a diathesis. And, for four of the five, we got through stuff a lot faster than we did, but she was the first person I worked with. And I was learning how to do this for the first time.

Rachel Handley: Wow. And it sounds like there's a huge range in what you say from your sculptor example to this lady who had three years

Steven Hollon: That's right. And again, I think we probably could have knocked it out in a year or less with this lady, maybe even less. But the sculptor didn't need the cognitive conceptualisation diagram, wouldn't bother doing it with them. This lady until we got that on paper, that was the, we had a couple of sheets of paper. We always had on the desk every time we had a session, and we'd be talking about what could you do with this new boyfriend? What would you try? Is that risky? What's on the line? How would you like to behave? What would you like to be able to do? And if you were, the new you, and then she would go from that.

Rachel Handley: So it sounds like in both cases, at both ends of the extreme, if you like, if we wanted to conceptualise it as a continuum, you're working with cognitions, that your sculptor had thoughts about his part in that he was flawed that it was a problem with him rather than a problem with strategy. But you are getting him in a very behavioural practical way to break down those strategies to test them out to do something different. With this lady there was a lot more involved in understanding why her compensatory strategies might have evolved why her beliefs what and what are maybe we might talk about core beliefs or what are quite fundamental beliefs about herself that there's a lot more working out to do in that, and a more prolonged period of understanding those strategies and testing those out

Steven Hollon: Yeah. That's a great summary, next time we revise the manual, if I can, I'd like to borrow your summary. Yeah. The sculptor didn't need the heavy artillery. The architect did. And she wasn't going to take the leap in a relationship that she was with somebody who's interested in easily because it scared the daylights out of her. She was so sure that it was going to blow up on her. She wasn't willing to take that chance. So having the stuff in front of her, gave her a little extra.

Rachel Handley: And this really illustrates to me something I've often noticed working with depression. I work a lot with anxiety, with trauma and social anxiety and these kinds of presentations. And often that feels like you're engaged in a kind of sniper fire. You've got a very clear set of cognitions that you go out and you test out, about blushing or about beliefs about the over generalised sense of danger in the world, you know what you're dealing with, you know what the trauma is, you know what the social anxiety is, what the panic cognition is. In contrast, sometimes working with depression feels more like guerrilla warfare. You don't know what's going to pop up when the patient comes in, what situation they're going to bring. The manual talks about being patient led in content, but therapist led in structure and that can lead to some therapist anxiety is like anything can come up any situation, shifting targets, thoughts. You've described a very beautifully illustrated, a kind of very complex piece of work that went on for a long period of time with someone who said they might, I might not even tell you the truth when I'm here, you've got some work to do to understand how things are for them. So what holds this all together when you're engaged in this guerrilla warfare and you don't know what's going to come up and you're preparing for a session? What holds it together?

Steven Hollon: Well, yeah, a couple things. Number one is, I always think the patient brings the content, we bring the process. So whatever content they walk in the door with, we're going to put that into our process. And they're not that, this is where we come back to the principles, they're only a couple things we want a client to learn and if they're depressed, it's don't wait to feel like it 'cause your dopamine is not working quite yet, but then the cognitive component of that is don't believe everything you think. Let's see what you believe and let's see how accurate that is. And the most powerful way to find out if what you believe is really true is to set it up in the real world and see what happens.

The architect was not going to believe, that, somebody she was interested in wasn't going to reject her until she heard a fact she was interested in. I could say anything I wanted to, the old girlfriend could say that, but you know, we got to it. Or have paid for doing that. So basic principle here is that there's certain things I want a client to do, which is, if it's depressed, don't wait. And by the way, the, sculptor was a lot easier to deal with because, for him to change his behaviour was no risk. It just meant mobilising his energy for the architect to change her behaviour. She was going to blow up a relationship or whatever else was going to happen.  For her it would make the world worse. If she was wrong, she, I mean, the world could get worse if it turned out the way she thought it was for the sculptor or wouldn't get worse, where we get better if it didn't turn out the way so easier to get somebody who's simply depressed to run a test to get somebody who's dealing with anxiety, or if it's depression superimposed on an access two disorder, which is depression. what was going on with in this case? It wasn't even access to disorder. she would make our turn for borderline, but she really, it was complex PTSD. her prior experience was such that awful things happen to people. They're in risky situations. So she was sure. So I'm not going to take this kind of risk unless you have a lot of reason to think maybe she can pull it off. We did a lot of, a lot of role playing with her that we didn't need to do with the architect and we've been role play anytime. She's going to have a conversation with the ex-husband with the new boyfriend with, my work, et cetera. We bro play. We bro play three different ways. What would be a passive way of doing it, which you usually don't ask, would be an aggressive way, which would be to demand, would be an assertive way, which is, I really like this from you. And if you do, I will do that for you, et cetera. you trade favours and we would do it all three ways. And, years later. As you have much improved and years later, ABC team wanted a symposium where people would identify toughest clients had worked with and I asked her because she was staying in touch as to what you'd be willing to do the videotapes did share as long as the camera shot over the back of her head. And we did. And one of the questions ABCG asked structured questions was, was there anything in therapy that you really didn't like? Said, oh, the role play, I hated the, I hated every minute of the role play. And a couple questions later were, what do you think was the most valuable part of therapy? Said the role playing.

Rachel Handley: So, So it's just like what therapists in training say.

Steven Hollon: exactly. Yeah, exactly. It's, it's,you put yourself on the line, then you take on risks and it's scary. But if you're gonna take a risk and do it with the therapist that you're paying or that's getting paid and not with the boyfriend, you don't want to lose. So there, there's sometimes when it's safer to take a risk than others,

Rachel Handley: So it sounds like the unifying principle is don't believe what you think, or don't just believe what you think, and the unifing process is let's test it out.

Steven Hollon: Let's test it out. let's find out what's really true.

Rachel Handley: So whatever comes, that's the framework we're putting it into.

Steven Hollon: And people, human beings are amazing that they can deal with virtually anything if they know what it is. It's the fantasy. It's the monster in the closet. That's really scary. It's most monsters and closets aren't as scary as the thing that you think is beyond the door.

Rachel Handley: And sometimes if I'm frank, the lives that I hear about in the clinical room or in supervision across services here in the UK, do seem to support a pretty negative worldview? So we've got patients are unemployed in situations of domestic abuse of one or more frequently more long term health conditions, few social supports, custody battles, housing problems, live in high crime areas, are battling addiction. It can feel a fair way removed from a depressed sort of white collar, middle class professional or artist. Often or often students presented in kind of depression textbooks, not that depression is any less real in those cases for those individuals, but what about the patient who barely makes it out of bed in the morning and can't begin to think about how they find social and financial resources, never mind the motivation or the energy to engage in behavioural activation? Does the model really apply in the real world? That's my question.

Steven Hollon: Sure. Because people are dealing with real world issues all the time, whatever their current status is, and people tend to the magnitude of the problem tends to be greater in people that have more. I mean, they see it as greater than somebody else that doesn't have as much to go with, but you're dealing with the same stuff and there's virtually nobody in a high crime area, who's not everybody in a high crime area is invariably depressed. Some things are worse than others. Nobody would sign their, 12 year old up for the concentration camp experience as summer camp, but, even people that deal with absolutely awful situations as bad as the situation is, if you keep your wits about you, you can reduce the impact on you, and it might be the best you can do, but at least get the best and move towards that. The sculptor, by the way, never got a job back in academia. When he was trying to do is interacting in the world. And in Minnesota at the time, Minnesota. Terribly cold winters. It was wintertime and he's at a donut shop. The way you get through cold winters is with fats, sugars, and caffeine. And he's reading the newspaper, finished the sports section, and some guy a couple stools over said, can I see your sports section? He handed it to him. The guy struck up a conversation. And he said, I've seen you from time to time. Who are you and what do you do? And the sculptor said, well, I'm so and so. But at this point, he was, he was done with therapy. He said, but I'm actually a sculptor by training. The guy said, sculptor? He said, yeah. Said, you ever thought about working for Tonka Toys? And the sculptor said no. He said, Tonka Toys is one of the world's largest toy manufacturers. They're out in Minnetonka, west of Minnesota, west of Minneapolis. He said, we hire sculptors. What we do is get them to turn the product design people's ideas into little scale models of the toys. Then we let the kids play with them to see what toys kids like. He went out there, he applied and got a job. He would not have gone back to academia. You don't know what you can do in the world until you start interacting in the world. And without relationships, there's always, they're always big brothers, big sisters. They're always people in the world that would benefit from having somebody a little older, who's going to take an interest in them. If there's nothing else, I'm going to go down to the animal shelter. I'm going to help feed and play with the pets. I'm going to do something that moves me in the direction that I want my life. If I ain't got it in my life right at the moment. And some problems you may or may not be able to solve. I mean, the death of a child, what could possibly be worse and the most depressogenic thing that we know about. But there are things you can do. One of the things we've learned, you throw yourself into the grief. You sit, you go through the photo albums, you have your little shrine in the home, you visit the grave sites, you might start coaching kids sports teams, et cetera. You don't cut yourself off and there's strategies that just work better than others.

Rachel Handley: Reminds me, hearing you speak about this of some of the work that Ed Watkins has done in rumination and how he talks about how there are problems you can't work out in your head that need to be worked out in the real world. And going back to where we started with this kind of evolutionary principle that we're shut down, that we're intensely focused internally, the memories are primed, the short term memories there, that we're not distracted that we're trying to sort things on our head that actually need to be sorted out in the real world.

Steven Hollon: It's absolutely brilliant. And he's really, he and Susan Nolen-Hoeksema might have really explored the role of rumination more thoroughly and better than anybody else. He's got some really lovely kind of approaches to dealing with that. Keep in mind when I talk about evolutionary perspective, most folks in the field, most depression experts would not agree with that. So that, and goodness knows, if you look at, my track record, I've been wrong more often than I've been right. I wouldn't bet money against Ed in the notion that rumination is the primary problem. It's not what I would bet money on myself, but, see where we go. I do think what we're doing is helping people structure the rumination. That's the adaptation of the brain involved to do when things make you really sad, then I want to facilitate the process and not leave you stuck. And I think what we do with cognitive therapy is teach people how to ruminate more efficiently. The three things I want a client to be doing when they have an automatic negative thought, the beginning of a rumination is say, what's my evidence for that belief? Any other alternative explanation for that? And even if it were true, if I don't know yet, what are the real implications? So, suppose you lose your job, first thought is, my God, must be because I'm incompetent. Well, any other things went wrong? Well, they've been downsizing. So maybe, a number of us lost our jobs. Maybe I was just the first out, et cetera. There's an alternative explanation, which is more consistent with the data. And as tough as it's going to be without my job, do I have unemployment benefits and how long do I have them for? What are the kind of jobs I want to pursue next? Is this a time when I want to take a chance in my life and try something I haven't tried before? They're the things you can do to get yourself mobilised which are not consistent with shutting down and doing nothing. And that's what we want to have clients move towards.

Rachel Handley: Also thinking about complexities in who we treat, you've spoken a bit about a patient who met criteria for borderline personality disorder or EUPD. What about patients with personality disorders or longstanding chronic impairment? The manual talks a bit about a three-legged stool. Is this where this principle comes in?

Steven Hollon: The biggest change in cognitive therapy since Beck first laid it out, the 1970s version that I trained in, has been dealing with more complicated clients. And the architect, the lady, we described it as a good example of that. She had a lot of other stuff going on. And the biggest problem was that she, and this is almost always the case with Axis I people with depression, superimposing Axis II disorders is that she had compensatory strategies that function like safety behaviours for her. She thought they protected her from loss from risk, etc. They didn't, but she couldn't know that until she dropped them, and she wouldn't know the role they played until she took the chance, takes a deep breath. With the sculptor, all he had to do was break stuff down into smaller steps. He's taken a risk to do that with just a matter of getting out in the garage and putting his portfolio together.

With the architect, she had to take chances in interpersonal situations that she thought she had something to lose. So laying out a roadmap for her about where did this come from? When did you first start believing this about yourself? What other evidence do you have? Let's talk about the times when you have had relationships blow up on you. What are the things that you've engaged in usually out of a sense of desperation, have they served you well? Have they really served you better than just levelling with your ex-husband or with your new boyfriend, et cetera about what happened to you at age 15 and see if they have any problem with that.

So for Axis II personalities, it's a matter of taking chances or giving up something that you really like. When Trump first got elected back in, what 2016, on that election we had our grad class on cognitive therapy the next night and everybody came absolutely dejected. So we talk about how would you deal with somebody with narcissism. And, say, look, if I were this guy's therapist, which of course I'm not, we'd walk out of the White House, we'd go out on the mall, I'd look, first to the left, see the Washington's Monument? You want one of those? How did Washington get that? Well, the father of our country, he gave up power voluntarily. He didn't try to, well, I don't know, at that point he was going to mobilise a mob. Then we look down the other direction, Lincoln Memorial, and say, how did Lincoln become the most beloved of our presidents? Well, he bound up the wounds. He didn't come down hard on the people that lost the war. He reintegrated them into the thing. So you look to helping out the people that are looking to you for help. You could do that as president. You'd be beloved, but you know, you do what you will. Who knew he was also a psychopath? But what do you know?

Rachel Handley: We can only hope, Steve, that you get to him before the next inauguration speech, which is upcoming as we record.

Steven Hollon: We can only hope, but I'm more likely to hit one of the concentration camps.

Rachel Handley: And the three-legged stool, there's something about how you use the relationship in therapy as well which that sounds all very psychodynamic.

Steven Hollon: And that's the biggest change in cognitive therapy. Tim and colleagues came up with that in the early 90s. In the 70s, most everybody we treated was depressed, but that's all they were, because in those days we were screening out folks with more severe disorders, and most folks were getting, 60, 70 percent were getting better within a couple of months. By the 90s, most people in the clinic were people that didn't get better fast, and they were simply the more complicated. They were the architects, not the sculptors. And, they had to come up with something different. And what Tim did say, look primarily in cognitive therapy, what we learned to do way back when was to focus on current life situation to get people to test the beliefs that lead to the behaviours that keeping them stuck in those situations. Now we got people that have essentially compensatory strategies. And those are the things that are actually getting them in trouble. You want to help them lay out where those strategies are coming from, what they think they're protecting them from, and then encourage them to test those. And he went to a three-legged stool. The first leg is what we always had done, which is focus on the current life situations and the beliefs, behaviours, etc. Second leg is the childhood antecedents. With somebody like the sculptor, I wouldn't bother talking about the past, once he's no longer depressed, rather than just talk about movies sometimes I go back to how'd you first get this way, just to tie a ribbon around the therapy, it might be a session or two at most.

But the architect would spend a lot of time going back over the end of scenes where this happened, was in her mind, the rape was not that traumatic, the fact that her father couldn’t have cared less and blew her off, that convinced her that she was without value, what have you. We kind of laid that out and would then go down to what are the core beliefs that you learned. The core belief for her, it was I'm unlovable. For her, it's I'm unlovable, for the sculptor it was I’m incompetent. What are the underlying assumptions? Underlying assumptions don't reveal yourself in a relationship and you won't get hurt. If you want something, don't ask for it directly because they're not going to meet you halfway. Manipulate. And those become the compensatory strategies. And it was the compensatory strategies which kept getting her in trouble.

Now, the third link is the therapeutic relationship. With the sculptor, I mean, it was like he was going to see his accountant or his mechanic. We came in, we talked, we did the stuff, and he left. With the architect, three o'clock in the morning the first week she's in therapy and I'm getting calls. Nobody's on the end of the line. You got a pretty good idea who that is. She's already manipulated me to have everyday sessions, done all kinds of things that I typically wouldn't do. It's quite clear that she's structuring the therapy in a way that's going to suit her convenience, the chance she wants to take, etc. So we lay out that third line, which is the therapeutic relationship. And anytime we put something on the agenda, how does that relate to what you learnt back when she was a teenager with her dad, and how we're working on that in here, anything about the way we worked on that, that rubbed you the wrong way? Anything reminded you about how pissed off you were at your dad or your ex-boyfriend, your ex, et cetera, et cetera. We touch all three legs of the stool. And then we'd use the interactions in the therapy session as, how would you say, they were stalking horse, and she could practice doing stuff with me before she was ready to do it with the people she really cared about out there.

And there were times, there was one time she came in, called, we were starting to space out the therapies, only doing a couple times a week now. And there was a Monday afternoon, we were going to meet on Monday. I'm a big fan of a football team- we have a different kind of football over here. They're going to be on Monday night football, unusual because there's a very bad team, I really want to get home to watch the thing at eight. She calls late afternoon, can I have a session? Something happened. Okay, you have a session, but I want to make sure I'm home by eight. Is that okay? She shows up half an hour late with a hot cup of coffee. And I'll look at her and say, that’s I’ve got this depressed, maybe borderline, possibly suicidal client. I said, that really annoys me. That really pissed me off. And she gets really upset. So, we spend about the first 15 minutes going over how upset she is, pissed off. How could I do that to her? And we end up having this nice discussion where, look, I will meet you halfway. I'll treat you like a real human being if you do the same for me. But, I'll cut deals with you, but I expect you to honour your deals with me. And that she, later on, would say that was a really major breakthrough. We used that as a model for how she can deal with people that she really cared more about. And if you're going to manipulate people, be ready to own up to it. And, and if they call you on it, that’s good. But, so we put all three of those together. We did that three-legged stool model that shows up in the manual. First time I'd ever done that, but we had that on the desk. And everything we did, we go each step, each, leg in there. So you're dealing with this bossy person at work, how's it relate back to what happened with your dad? And how's it relate to how you and I are working together? We touch at each leg of the stool. And it didn't always have to, but it helped him enough of the time that for somebody who's dealing with depression superimposed on Axis II disorder, where they're used to either manipulating or avoiding or doing stuff with other people, where what they do is screw up their lives continually because of the way they treat other people it helps them understand that. And we're working on that in the therapy session itself.

Rachel Handley: Yeah. So we often reflect in this podcast that being a therapist is an incredible privilege, the best, most rewarding job. But let's face it, it can be a tough one as well. Our own lives aren't always free of complications and challenges that make it harder when we're maybe we're working with depressed clients. What you've just described is some pretty complex interpersonal dynamics, the kind of having to make a decision to share your own anger, your own response to that hot cup of coffee that arrived in your therapy room. How might we be challenged by this work and how do therapists look after themselves and maintain that therapeutic stance?

Steven Hollon: Yeah, that's a great question. I had 3 episodes of major depression in my early 20s; last year in college, the year between when I was working as a therapist at a communal health centre and my first year in graduate school, and nothing since I hit Philadelphia. Whatever I've been learning to do with my clients ha been working like a charm for me. And that's not usually the way the life course goes. There's something derailed the typical progression in my life. And I think it's what I learned to teach other clients to do. The second thing I learned in the whole process is that. is if you think something might be, you don't want to do things that are rude or harsh to somebody else unless you've already built a good relation, in which case you can ask for a minute and go and do that, but if you have an impulse to do something for God's sake, do it. The biggest errors we make as therapists is not acting. And its because depressed clients are not acting. They know what they want to do. In most of our trials, the toughest people to treat are people with chronic depression. And it's not usually the case that they don't have a notion as to what they could do in their life that might make it better, but they're not willing to take those chances. And, what I've learned in my professional career, my therapeutic stuff is, if you think something might be worth trying, for God's sake, try it. Ask permission first if needs be, to clean up the mess afterwards, but I think the mistakes I've made have been more likely errors of omission than errors of commission, and you've got a client you're working with, they've gotten to know you a little bit, they'll usually cut you a little slack.

Rachel Handley: So don't get stuck in behavioural inactivation.

Steven Hollon: Don't get stuck, don't get stuck in behaviour and not acting.

Rachel Handley: I guess it's also really important to us as therapists to know that what we're doing has a high chance of, or a good chance at least, of success. what is the,effectiveness, efficacy of cognitive therapy for depression now, and is it effective for everyone?

Steven Hollon:  No it's clearly not. A short term with a relatively uncomplicated person, relatively uncomplicated depressions, not chronic depression 10 to 20 sessions is going to be enough and in the last third of it you're going to be talking about other stuff. So for the sculptor, we had more sessions than we needed. For the architect, we needed more sessions than we had, although things continued on. I think it depends on how many episodes, how long the person's been depressed and other kinds of complications. If I get somebody who's depressed and has panic attacks, I'll ask if we go after the panic attack first, because that's a session or two. If I get somebody now, who's depressed on top of PTSD, I think we have to go after  PTSD first. We do the reliving quick because that I mean, you can get rid of the PTSD symptoms rapidly with the reliving, then you got all the trauma, the meaning there to deal with, but that's going to be part of it as well. And that usually moves faster than the depression per se.

Social anxiety takes longer. And that's the anxiety that sort of reminds me more of depression than anything else. And it's not always the self that’s the problem its usually other people, you never know when they're going to turn on you, but usually there's a history of having been bullied something else. So there's often a self-involvement there as well. And I've not done much work with people with serious mental illnesses, at least not much successful work, but you guys have in England and you're good at it. And I remember we had a marvellous therapist out of the Maudsley that came over and did a weekend long workshop for us over here. She would describe a client and then ask people in the room what they would do. And I would usually be quick to volunteer. And I'd say something and it would be like, no that’s too soon, build a relationship first too soon. So, the one thing I learned out of that is don't rush. Got a depressed client- rush. He who hesitates is not serving his client or her client well. With somebody who's got a propensity to decompensate, take your time, let them get to know you, get to trust you, and then put stuff in. But you guys are much better at that than we are we're in the States, we're trained that you can't reason with somebody who's psychotic. And in England, you guys do it and it works.

Rachel Handley: So it sounds like really important factors in the effectiveness of this therapy are going to be things like chronicity, severity, comorbidity and type of comorbidity, very importantly, whether it's severe mental illness or different problems that you can deal with.

Steven Hollon: Can I comment on that? I think that's great. But I would start with that tucked in the back of the mind. I would probe to find out. I wouldn’t assume just based on, I would take my Sally's. It's like you're sending out a group to see where the gunfire occurs in the war zone. You never know for sure. And don't assume that something's going to be tough until you find out that it's tough.

Rachel Handley: So someone walks into my office with unipolar depression, maybe it's the second episode in adulthood. Is there such a thing as an answer when they ask me? What are the chances of me getting better, Doc, when you've done cognitive therapy with me?

Steven Hollon: Yeah, they're pretty good. And the question is, I mean, there are other kinds of therapies that work as well and great if this kind of thing works for you. By the way, it won't work if you don't take it, don't use it. It's like medications. You can't just hold the pill in your hand and expect it to do anything for you. But if you work on the therapy, try this stuff out, take a few chances, risk, et cetera, then we'll find out the odds are about 6 to 7 out of 10 that it's going to work for you, in a relatively short period of time. And by the way, if it works for you the odds are it's going to cut your risk by at least half for having future episodes. So not a bad bargain to get into, can't guarantee and I never want to make a promise, I can't guarantee. But we do know how to find out and it's to do the stuff and see what happens.

Rachel Handley: So perhaps a bit controversially, we could say, well, we've reached the limits of cognitive therapy. It's going 50 years on, maybe there's a 6 or 7 out of 10 odds chance you get better, maybe less, maybe more depending on your presentation. Have we maxed out on recovery and remission now? Is cognitive therapy standing still or can it still improve?

Steven Hollon: Yeah, it's a great question, but I think it's evolving. I think we've learned how to do things starting with the focus on the Axis II disorders that we didn't know how to do back when I first went through training and my hunch is most people that know how to do cognitive therapy haven't learned yet how to do that stuff. I think I'm a better cognitive therapist today than I was back in the 70s and I think I'm better cognitive therapist today than I was when I started working with tough clients like the architect. So, I think thats the trajectory for any given therapist as well. And I think I'm learning things. I've been watching the tapes that David and Anke put on the OXCADAT training tapes for social anxiety and PTSD and I’m a bit further along with PTSD, social anxiety, still a bit of a mystery. I don't quite understand anxiety, but I mean, amazing training tapes. So, I don't think we've got close to maxing out at all.

Rachel Handley: And you've spoken a little bit already about the Philadelphia effect when you started doing this work, it helped you in terms of, as you reflect back, you haven't had further episodes of depression, you've been able to implement some of the tools and strategies. What have you learned most, do you think, from the people you've worked with? Is there any lesson or individual that stands out as someone you really impacted in your life?

Steven Hollon: Oh, I mean, Tim Beck was just an absolute marvel. When Tim turned 100, Judy Beck and Rob DeRubeis set up a birthday thing for him, and about a dozen people came in by Zoom and we were going to share some kind of anecdote. We all basically told the same story. Tim identified something in us when we were generally early in training, graduate student, resident, et cetera, that he then nurtured over the course of our careers. And, just remarkable that, this is a guy who was an outcast in his own field, totally dismissed, totally ostracised, but he stuck to the data, and he built something really very positive out of that. He also, enlarged, expanded, what he was doing, went beyond the narrow structures in a way that is marvellous. I mean, other folks as well. I've learned so much from people like Anke Ehlers and David Clark and others and the marvellous folks down at the Maudsley; Sheena Liness and Suzanne Byrne and others, I come to, England from time to do training workshops, and I've learned more than you guys learned from me when I come.

Rachel Handley: And what about from your patients?

Steven Hollon: So much. I mean, you learn different things from different patients. Nobody ever worked me at and down the other more than the architect and I ended up being more of a friend than a former client, but just remarkable. And, most of the time I was flying by the seat of my pants. You trust your gut and you do what you do. And if something screws up, then you work your way through that. It's like any other kind of relationship you don’t know coming in with the other person's going to like it, you work your way through, you get feedback and you go from there.

Rachel Handley: It's something really freeing. Yeah, there's something really freeing about that message around not getting stuck, not getting paralyzed in our work.

Steven Hollon: Yep you learn more from tough patients. And, when I come over from time to time and get a chance to do the workshops, often we'll spend the second day, just going over, bring your toughest cases, the people you have the most difficulty with and we’ll role play around that. And sometimes we invent stuff on the fly, we come up with things we hadn’t anticipated. One of the things about cognitive therapy is Tim would always say we'll steal from anybody. And if it's a good idea, he'd incorporate it. And we keep the spirit there. If it's a good idea, then you bring it in.

Rachel Handley: So it's important to pursue what works?

Steven Hollon: Yeah, and it's important not to worry about whether or not it's going to work enough before you pursue it. Roll the dice, see what happens, and correct your errors.

Rachel Handley: Test it out. So if people want to learn more about your work, Steve, where can they access training? You've spoken about coming to the UK and doing training here. I'm sure you're doing lots in the States. Where would you direct people if they wanted to dig deeper into this?

Steven Hollon: Yeah. Well, again, you guys got, these recordings. I don't know if, Sheena and Suzanne, I usually, each year I've been coming to the Institute, the Maudsley, like I don't know if they tape those things. There are other folks I come over that I do trainings for that tape. I think in May, I'm scheduled to do three; one at the Maudsley, the other two- is there an Oxfordshire one and the 3rd place and I don't know, if they're taping those things, often they do and those may will be available. It's funny I do more training in the UK than I do in the States and because again, we're so when it comes to depression, we're so cognitive behavioural as opposed to cognitive and for anything else. Again, the basic principles you get from the marvellous training tapes that David and Anke put up on the OXCADAT site. And, I'll be teaching a course this semester, graduate course on cognitive therapy and the depression stuff I'll handle. We'll have examples and tape some things, but for the last third of the course, we'll go to the OXCADAT and watch tapes together and talk about what they have. So that again, the marvellous source of training,

Rachel Handley: Fantastic. And of course, as we've spoken about a lot, there's this new manual, that, that is last published last year and really worth a look. Look, I still have my old version, my first edition, which was, and I know we're not supposed to have superstitious beliefs as cognitive therapists, but it was signed by Beck. So I'm never going to be able to relinquish that because that will clearly make me a bad therapist if I dropped the book,

Steven Hollon: if you didn't have time, there's the revision. I'll be absolutely amazed but do your best.

Rachel Handley: that might be beyond even my superstitious reach. So in CBT we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key message would you like to leave folk with?

Steven Hollon: I would say always the cognition is primary. What somebody believes is what you really want to know. But different kinds of disorders are going to play in different kinds of ways. If it's depression, usually people aren't moving, going to be better for them if they do it. Do you want them testing stuff out? So you really try, usually trying to activate them. And that usually is going to mean taking stuff they're trying to do that isn't working well or not even trying and break in small steps of behavioural components. Very useful there. But always it's the test in the real world that matters the most. But what you want to test is the belief that they have and other things, and again, so often you get other things in the midst of the depression, the anxiety, the phobias, the trauma histories, et cetera. Yeah. find out what they've come to believe, and then, see what, see what evidence they would find compelling to help them change their belief. It doesn't matter what you find compelling. It matters what they would find compelling, then help them move on that to run those tests. Always in the session, there's going to be somebody in the session that knows the most powerful test to run of a belief, and that's going to be the client himself or herself. It's the last thing they want to do, and find out what's the last thing they want to do, particularly if there's any anxiety involved, and encourage them to do that. And when they do, then they find out whether they needed to be afraid.

Rachel Handley: And I'm taking away from this as a therapist, not just that message for work with my clients, get them to test it out, But to test stuff out myself, not get stuck in that paralysis. And we can all make mistakes, but they can be fixed. they're all grist of the mill

Steven Hollon: When you say this is a really tough client, that's the beginning of the conversation, not the end. And then you say, did the stuff we know how to do, is that likely to work? Let's try some of that stuff, but if not, what do I have to invent? We've got to come up and then involve the client in coming up with that. The architect was remarkable in the way she helped modify and redesign the therapy with me.

Rachel Handley: And the rewards are great if we can help people live more fulfilling, happier lives.

Steven Hollon: Yep. That beats parking cars.

Rachel Handley: Thank you so much, Steve. It's been so interesting talking to you. As I predicted, we could have gone on a lot longer, so many questions, but this has been really helpful. Thank you very much for your time early out there, in the States. So thank you for joining us.

Steven Hollon: Been a great delight and thanks so much. Much appreciated.

Rachel Handley: Well, if you've made it to the end of this podcast, perhaps like me, you'll want to go back and listen again. There is so much in what Steve had to say. We have more coming up soon on our series on depression, so watch this space and until then, look after yourselves and look after each other.

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