Termination and Relapse Prevention (Session 16)

Chapter 8 addresses common issues associated with treatment termination and recommends strategies and tactics for addressing end-of-treatment issues, including relapse prevention and maintenance of longer-term change processes that were started during therapy. Short-term, structured therapies such as self-system therapy (SST) help clients develop the necessary skills to continue the work of therapy after termination. SST aims to reduce the symptoms of depression and comorbid anxiety through improved self-regulation. Because depressed clients often fail to recognize their progress or may attribute gains to external causes, the therapist should underscore clients’ central role in the progress that has been made and encourage them to acknowledge their efforts. Continued use of the described strategies and tactics can equip clients to pursue their goals, evaluate themselves in a realistic way, and get closer to being who they want to be.

Is Self-System Therapy Right for Your Client?

Self-system therapy (SST) is an appropriate treatment for clients with a primary diagnosis of major depressive disorder (MDD) or persistent depressive disorder, with symptom severity ranging from mild to severe using standardized measures. SST was developed for individuals with depression characterized by problematic self-regulation, but it can also be used for treating comorbidities such as anxiety. Clients should receive a thorough diagnostic evaluation and medical examination to rule out nonpsychological causes of mood disturbance. Diagnostic assessment also includes a determination of whether the client meets the criteria for MDD, identification of contraindicated comorbidities, and a comprehensive evaluation of the client’s current problems and strengths. Chapter 3 discusses the recommendations for determining whether a client can benefit from SST and includes guidelines for diagnostic assessment.

Introduction to This Guide

Depression is one of the most common forms of mental illness, and mental health professionals in a variety of practice settings have witnessed its debilitating effects. Many pathways can lead to depression, and no single approach to treatment is successful for all clients. Chapter 1 provides an overview of self-system therapy (SST), a treatment approach that targets deficits in self-regulation. Research has shown that SST is as effective overall as cognitive therapy and that it leads to better outcomes for a subset of depressed clients who struggle with self-regulation. Suggestions are given for how the Therapist Guide and Client Workbook should be used for the treatment of depression.

Overview of Self-System Therapy Strategies

Chapter 4 introduces the core strategies in self-system therapy (SST) and discusses how SST is similar to and different from other short-term, structured therapies, such as cognitive-behavioral therapy, interpersonal psychotherapy, behavioral activation therapy, and acceptance and commitment therapy. SST focuses on self-regulation as a motivational process and targets how clients go about setting, pursuing, and monitoring important personal goals that are defined in part by discrepancies between self-beliefs and self-guides. SST is a structured clinical intervention based on a self-regulation model of depression and involves three phases of treatment: orientation, exploration, and adaptation. Flexibility within this structure allows therapists to tailor strategies, tactics, and assignments to fit the unique needs of each client.

Theoretical Overview

Chapter 2 introduces the theory underlying self-system therapy (SST). The terminology and concepts of SST are clarified for therapists and their clients. Self-regulation is a motivational process involving ongoing comparisons between the actual self (i.e., the person I am) and the ideal self (i.e., the person I want to be) or ought self (i.e., the person I should be). Self-beliefs are characteristics that define the actual self, and self-guides are characteristics that define the ideal and ought selves. SST’s core concepts include self-discrepancy and regulatory focus, and the chapter discusses how those concepts relate to goal pursuit, self-evaluation, characteristic orientations, and depression.

Adaptation Phase (Sessions 9–15)

Chapter 7 provides a session-by-session guide to the adaptation phase of self-system therapy, which focuses on reducing chronic, distressing self-discrepancies and modifying unsuccessful patterns of self-regulation. The approaches and tactics used by therapists can be broadly categorized as altering one or more of the maladaptive aspects of self-regulation or as compensating for aspects of self-regulation that are not optimal targets for change. To address various clients’ therapy goals, the therapist can use three freestanding modules, each of which has a broad goal for the final phase of treatment, and they can be completed in any order. The Module 1 goal is to reduce self-discrepancy and increase self-congruency; the Module 2 goal is to modify the client’s regulatory style; and the Module 3 goal is to manage perfectionistic tendencies. The therapist uses the adaptation phase of therapy to help the client reduce self-discrepancies, modify regulatory style, and manage perfectionistic tendencies.

Exploration Phase (Sessions 5–8)

Chapter 6 provides a session-by-session guide to the exploration phase of self-system therapy (SST). This phase involves assessing important aspects of the client’s self-regulation, including self-knowledge and regulatory style. The therapist applies two tactics specific to SST. Self-belief analysis is used to examine the content, function, origins, and adaptiveness of the client’s beliefs about herself or himself in relation to others, with an emphasis on goals and standards. Psychological situation analysis is applied to evaluation of the client’s goals and standards in everyday situations to determine his or her typical patterns of self-regulation. The therapist and client then construct a revised problem formulation and a set of specific targets for reducing self-discrepancies and improving the effectiveness of self-regulation.

Orientation Phase (Sessions 1–4)

Chapter 5 provides a session-by-session guide to the orientation phase of self-system therapy (SST). The main goals of orientation are to familiarize the client with the structure and focus of SST and to establish a strong, collaborative working alliance that supports the client’s efforts in identifying and addressing underlying sources of problems in self-regulation. The orientation phase involves educating the client about self-regulation, reinstating goal-directed activities, conducting a self-in-context assessment, and developing a problem formulation. The therapist completes an evaluation of the client’s presenting problems, introduces the idea of self-regulation, and searches for the possible origins of self-guides and standards to develop a formulation of the problems with self-regulation that are most directly associated with the depression. SST emphasizes the breakdown in motivation that characterizes episodes of depression and uses the orientation phase to begin to increase the client’s level of goal-directed activity (especially promotion-oriented activity) and identify targets for change.