Socialization to Treatment The patient should be told that his or her diagnosis is depression as soon as the initial assessment is completed. Each patient should be given a patient handout about depression and asked to begin reading a self-help book. It is helpful to point out to patients that we use several models of depression. Specifically, we indicate that depression is associated with decreased rewards and increased negative events, problems exhibiting appropriate skills and behaviors, and a lack of affirmative behaviors; to negative trends in thinking and unrealistic standards of perfectionism and approval seeking (cognitive models); conflicts and losses in personal relationships (interpersonal model); and to biological factors influencing brain chemistry and familial vulnerability to depression (biological model). We emphasize that these models are not mutually exclusive and that interventions from each model will be used. Part of the socialization process is providing the patient with a case conceptualization and treatment plan. After assessing the patient's condition, the therapist and patient explore a conceptualization of the current problem. This conceptualization may include a schema of behavioral excesses and deficiencies; samples of life problems; typical automatic thoughts, assumptions and patterns; and examples of how the patient avoided or compensated for his individual schemas. It may also include hypotheses about earlier life experiences that may have led to specific assumptions or patterns. The treatment plan may include behavioral, cognitive, interpersonal, marital/family, and biomedical interventions that may be considered relevant. Another part of socializing patients is to specify what the therapy will be like and what we expect from them as patients. Cognitive behavioral therapy is an active, here-and-now therapy that requires the patient to self-help. This is collaboration. It is helpful to familiarize the patient with the treatment model. We also find it helpful to review with the patient the reasons why he or she may be reluctant to do homework in therapy, or the assumptions the patient may have about the need to disclose early life events in the psychodynamic process. Goal Setting Goal setting is important for all patients , but especially for depressed patients who feel hopeless. The clinician can help such a patient identify goals for the next day, several days, week, month, and year, constantly connecting the patient to a proactive position in the future. Results from responses to several self-report scales (eg, QIDS-SR16, BDI-II, and BAI) can be used as symptom targets or goals that the patient should review periodically to assess progress. Short-term goals may include increasing behavioral activity, seeing friends, exercising more, or getting work done. (Initially, a short-term goal may be quite simple, such as filling out forms or moving on to the next session.) Long-term goals may include taking a course, obtaining a credential, losing weight, or changing jobs. Additionally, deeper life goals can be explored, so this therapy is not only aimed at overcoming depression, but also at creating a worthwhile life. Such deeper goals may include being a better spouse/partner or parent; become a best friend; development of character strengths (honesty, courage, compassion, kindness); or by pursuing other values ​​that give meaning to life. The therapist and patient may agree to periodically review all short-term and long-term goals. Sample Plan of Goals and Interventions for Depression Goal: Elimination of suicidal ideation Intervention: Cognitive restructuring, elimination of access to funds, drawing up a contract with the therapist,developing strategies to overcome suicidal impulses; development of short- and long-term goals Goal: Reduce hopelessness Intervention: Explore causes of hopelessness, examine evidence for and against, behavioral experiments, activity planning Goal: Participate in one rewarding activity/day Intervention: Reward planning, activity planning, differentiated task Goal: Reduce negative automatic thoughts Intervention: Cognitive restructuring, Mindfulness Goal: Sleep 7-8 hours/night Intervention: Relaxation, insomnia treatment plan Goal: Reduce rumination Intervention: Anti-rumination interventions, metacognitive therapy techniques Goal: Engage in one assertive behavior/day Intervention: Affirmation training Goal: Increasing rewards for positive behavior (one day) Intervention: Reward planning , Self-help Goal: Changing maladaptive assumptions Intervention: Cognitive restructuring, behavioral experiments Goal: Changing the futility schema (or other schemas - specify) Intervention: Cognitive restructuring, developmental analysis, working with schemas, empty chair technique, writing letters to schema sources, developing adaptive schemas Goal: Elimination Impairment (specify - depending on the impairment, there may be multiple goals) Intervention: Cognitive restructuring, problem-solving training, or other skills training (specify) Goal: Acquire relapse prevention skills Intervention: Review and practice techniques as needed Behavioral activation and other behavioral interventions Behavioral activation (Reward planning and activity planning)Increasing helpful and productive behavior in a depressed patient is one of the first goals of therapy. Behavioral activation, which combines reward planning and activity planning, is a means to achieve this goal. As a first step, the clinician provides the patient with a weekly activity chart to track the activities in which he or she engages during each hour of the day and to note the amount of pleasure and mastery (feelings). achievements and effectiveness) that were actually experienced during each event. This allows the patient and therapist to review how the patient's time is being used; whether the patient usually plans activities; whether many or most current activities are monotonous, ruminative, antisocial and/or dysfunctional (this is usually the case); and which of these activities are associated with the highest and which with the lowest degrees of pleasure. The therapist then considers the patient's activities that were once enjoyable but which the patient performs less frequently, or activities that the patient believes he or she could enjoy, but never tried, and encourages the patient to begin planning more of these activities and fewer low-impact activities (watching TV in bed, thinking, etc.). The patient is then assigned to plan some of these activities for each day and uses the patient's weekly planning schedule to predict the amount of pleasure and skill he or she expects to have from each. Finally, the patient actually participates in the activities and again uses the form to record his or her actual ratings of mastery and enjoyment. The therapist can introduce a cognitive component to the behavioral activation process by having the patient compare expected and received pleasure readings (as a test of negative divination); Help the patient see that pleasure depends on the activity and that he or she can control the amount of pleasure achieved; and by having the patient explore automatic thoughts associated with various actions. For example, depressed patients often have discounting thoughts (“that wasn’t as good as