BEHAVIORTHERAPY22, 579-595, 1991

Cognitive Behavior Therapy Manual for Depressed

Inpatients: A Treatment Protocol Outline
MICHAEL E . THASE

University of Pittsburgh School of Medicine

JESSE H. WRIGHT
Norton Psychiatric Clinic
University of Louisville School of Medicine

In this report we present a brief treatment manual for the use of cognitive behavior
therapy (CBT) as an inpatient treatment of nonpsychotic major depression. The manual
was developed primarily for use by experienced therapists working on general, short-
stay psychiatric inpatient units. Inpatient CBT differs from outpatient therapy in terms
of the frequency of sessions, a relatively greater emphasis on behavioral strategies early
in the course of treatment, and the need to integrate therapy within respect to a broader
multidisciplinary treatment plan.

Recent surveys indicate that most depressed psychiatric inpatients receive

some form of psychotherapy or psychosocial treatment (Margo & Manring,
1989; McCarrick, Rosenstein, Milazzo-Sayre, & Manderscheid, 1988). How-
ever, such treatment has received surprisingly little empirical investigation
(Margo & Manring, 1989; Markowitz, 1989). Among the several forms of psy-
chotherapy developed specifically for depression, cognitive behavioral therapy
(CB'R, Beck, Rush, Shaw, & Emery, 1979) has received the most extensive study
and replication in outpatient settings (e.g., Beck, Hollon, Young, Bedrosian,
& Budenz, 1985; Blackburn, Bishop, Glen, Whalley, & Christie, 1981; Elkin,
Shea, Watkins, Imber, Sotsky, Collins, Glass, Pilkonis, Leber, Docherty, Fiester,
& Parloff, 1989; Murphy, Simons, Wetzel, & Lustman, 1984; Rush, Beck,
Kovacs, & Hollon, 1977; Teasdale, Fennell, Hibbert, & Amies, 1984). Indeed,
several groups have developed speciality inpatient units centered around be-
havioral treatment programs (see, for example, Beck and Rush, 1988 or Bowers,
1989).

Completion of this manual was supported in part by grants MH-41884-03 and MH-30915
(MHCRC) from the NIMH. We thank Ms. Lisa Stupar for her assistance in preparation of the
manual and Drs. Aaron T. Beck, Edward Craighead, and Randy Schrodt for their helpful com-
ments on earlier drafts.
Please address correspondence to: Michael E. Thase, M.D.; Western Psychiatric Institute and
Clinic; 3811 O'Hara Street; Pittsburgh, PA 15213.

579 0005-7894/91/0000-000051.00/0
Copyright 1991 by Association for Advancementof Behavior Therapy
All rights of reproduction in any form reserved.
580 THASE & WRIGHT

The utility of inpatient CBT as a primary treatment has been described in

selected cases (Bishop, Miller, Norman, Buda, & Foulke, 1986; Scott, 1988;
Shaw, 1981) and two published studies have documented the value of adding
cognitive and behavioral therapies to inpatient pharmacological treatment
(Bowers, 1990; Miller, Norman, Keitner, Bishop, & Dow, 1989a). The further
development of inpatient CBT to the inpatient setting may be facilitated by
the availability of a standardized treatment manual. Such manuals permits
the therapy to be administered in a reproducible and valid fashion across many
settings and also may improve the internal validity of research utilizing the
therapy (Elkin, Parloff, Hadley, & Autry, 1985). In this spirit, the following
manual for inpatient CBT was developed.
Rationale for Inpatient Cognitive Behavior Therapy
Beck's model of cognitive behavior therapy (CB12, Beck et al., 1979) was
chosen for several reasons. First, CBT's efficacy with outpatients suffering from
major depressive disorder has been convincingly demonstrated (Craighead,
Evans, & Robins, in press; Rush, 1983; Perris, 1989). Second, CBT is both
applicable in combination with antidepressant medication (Wright & Schrodt,
1989) and has been reported to be an effective primary treatment of more se-
vere, "endogenous" depressions in the outpatient settings (Blackburn, et al.,
1981; Teasdale et al., 1984; Thase & Simons, in press). Third, the structured
and symptom-focused methods of CBT are well suited for use with more se-
verely depressed inpatients (Bowers, 1989). Fourth, the cognitive focus of treat-
ment is particularly useful for patients with suicidal ideation (Freeman & White,
1989). And fifth, CBT's emphasis on learning skills for relapse prevention
(Perris, 1989; Persons, 1989) may be particularly useful for preparation for
discharge from the hospital.
Selection of Patients for Inpatient CBT
Constraints imposed by utilization review policies, cost containment efforts
of third-party payers, longstanding psychiatric biases, and a dearth of empir-
ical data provide a strong, contemporary justification against the routine use
of CBT as the primary treatment for depressed inpatients. Nevertheless, there
are several circumstances for which inpatient CBT may be considered as a pri-
mary treatment of nonpsychotic (nonbipolar) major depression. These situa-
tions include: 1) patients who are adamantly opposed to treatment with medi-
cation, 2) patients who either cannot safely take or have not tolerated most
standard antidepressants, 3) patients who have not responded to a number
of antidepressants and who do not wish to receive electroconvulsive therapy,
and 4) women who are either pregnant or breastfeeding.
There are few absolute contraindications for use of CBT in combination
with pharmacotherapy. Combining CBT with electroconvulsive therapy may
prove inefficient (due to the latter treatment's short-term amnestic effects) but
would not represent an absolute contraindication. Similarly, mildly demented
depressed patients may have a more difficult time with therapy, but again it
would not be an absolute contraindication. Finally, although as a use of CBT
with patients with bipolar affective disorder has not been well-studied, some
 I N P A T I E N T COGNITIVE T H E R A P Y PROTOCOL 581

evidence suggests that therapy may improve treatment adherence and overall
outcome (Cochran, 1986). The remaining conditions in which inpatient CBT
would be relatively contraindicated are few; moderately to severely mentally
retarded patients would represent one extreme situation, as would patients
who are essentially stuporous or catatonic.
Therapists
We recommend that inpatient therapists have: l) completed an intensive
supervised training program; 2) received external certification using a stan-
dardized measure (i.e., the Cognitive Therapy Scale; Vallis, Shaw, & Dobson,
1986); and 3) obtained at least one year's experience treating outpatients with
CBT with an acceptable rate of response (i.e., > 60°7o response rate). Such ther-
apists must be able to work collaboratively with the inpatient treatment team.
We also recommend that CBT therapists receive some form of ongoing super-
vision to help maintain fidelity and adherence to the model.
Modifications o f CBT for Use on an Inpatient Unit
The nature of contemporary hospital practice dictates certain modifica-
tions in the delivery of CBT. For example, the average inpatient will be more
severely depressed than the average outpatient, yet the length of stay may
only range from 14 to 28 days. Therapy thus needs to be intensified in fre-
quency while tailored to provide a slower pace within sessions to prevent over-
burdening a severely depressed patient (Scott, 1988). Wright and Schrodt (1989)
use a three times a week CBT program, while others (Bowers, 1990; Miller
et al., 1989a; Scott, 1988) utilize four or five day a week protocols. We recom-
mend daily sessions (i.e., minimum of five per week) when CBT is the primary
modality to maximize the "dose" of therapy. Other modifications center around
the greater likelihood that patients will have made a suicide attempt or will
have active suicidal ideation. An initial emphasis on recognition of hopeless-
ness and identification of specific strategies which lead to a reduction of hope-
lessness are essential. Patient severity also may require a greater emphasis on
behavioral interventions early in the course of inpatient therapy (Bowers, 1989;
Scott, 1988; Shaw, 1981). Behavioral methods, including graded task assign-
ments, scheduled pleasurable activities, relaxation training, and thought stop-
ping, are selected following assessment of the patient's difficulties. In partic-
ular, we make liberal use of relaxation training when concomitant medications
are not prescribed.
Other modifications are related to the need for treatment planning and the
role of the multidisciplinary treatment team. Inpatient CBT must fit well into
an integrated treatment plan. The therapist will need to develop a written ad-
dendum to the basic inpatient treatment plan, and regular attendance at treat-
ment team meetings is an important way to integrate the therapy into the overall
assessment of progress. Although each member of the treatment team con-
tributes are area of strength, there also may be areas of potential nonalliance.
For example, the attending psychiatrist (and, in a teaching hospital, the resi-
dent psychiatrist or medical student) may indirectly communicate the belief
that CBT is a less important component of the patient's treatment plan, un-
582 ~ S E & WRIGHT

dercutting the patient's efforts in therapy. Social work staff similarly may not
be able to describe convincingly the rationale, methods, or strategy of therapy
to the patient's family. Nursing staff, by virtue of their greater frequency of
contact with patients, may need additional supervision in order to provide
optimal supervision of homework assignments. Whenever possible, we recom-
mend that the primary nurse serve as a co-therapist and that an initial con-
joint meeting is held including the social worker, the patient and his/her
spouse/significant other, and the therapist.
Assessment o f Outcome
Objective indicators of readiness for discharge include: 1) an overall reduc-
tion of ~>50°70 in the severity and/or frequency of complaints of dysphoria
and associated symptomatology; 2) increased capacity to resume activities of
daily living; 3) reduction of suicidality, hopelessness, or impulsivity (a total
elimination is strongly preferred); and 4) identification of use of the therapy
as a means to cope more effectively with life problems. The criteria should
be met for at least five days prior to discharge. Objective measures of improve-
ment include the Beck Depression Inventory (BDI; Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961) and the Hamilton Rating Scale for Depression
(HRSD; Hamilton, 1960).
Continuity o f Care
There is a high rate for relapse during the first several months following
hospitalization (Belsher & Costello, 1988; Thase, 1990). Clinical correlates for
relapse include high residual depression ratings (Simons, Murphy, Levine, &
Wetzel, 1986), significant ongoing life stress (Belsher & Costello, 1988), and
inadequate aftercare (Thase, Bowler, & Harden, 1991). Therefore, planned
aftercare is essential. Our current approach specifies that, when CBT is uti-
lized as the primary therapy, a period of four months (i.e., 16 sessions) of out-
patient continuation therapy is provided following discharge. This provides
additional support during the time of transition to outpatient status, allows
for the consolidation and further practice of new skills learned in the hos-
pital, and promotes further work on underlying cognitive vulnerability. Such
continuation therapy may have clinically significant results (Miller, Norman,
& Keitner 1989b).

The First Week of Therapy

The major goals of the first week of therapy are to: 1) establish a collabora-
tive alliance between the patient and therapist; 2) introduce and illustrate the
cognitive model of depression and its treatment; 3) identify a problem list (in-
cluding symptoms and ongoing life problems); and 4) begin to implement ther-
apeutic change on the most pressing or troublesome issues, including a reduc-
tion of hopelessness or suicidality. Excellent descriptions of the specific
procedures employed in CBT are available elsewhere (Beck et al., 1979;
McMullin, 1986; Persons, 1989).
 INPATIENT COGNITIVE THERAPY PROTOCOL 583

Week 1 - Session 1
The first session provides an introduction to both the model and process
used in CBT. Development of a collaborative alliance is essential, and the ther-
apist will elicit questions and address potential areas of confusion or difficulty.
The following general outline is employed in the initial session:
Patient and therapist introduction. The therapist greets the patient in a warm
but professional manner. Preliminary questions usually address the patient's
knowledge of depression and CBT.
Setting an agenda. The agenda introduces the relatively structured approach
of CBT. The agenda serves to provide a coherent sequence to provide organi-
zation and maximize efficiency and productivity. The therapist explains that
each session will follow an agenda. The initial session's agenda includes ob-
taining the patient's history and developing a problem list.
Brief review o f the patient's history. Although the therapist has reviewed
the chart and discussed the patient's case with the treatment team, it is impor-
tant to provide an opportunity for patients to describe their histories prior
to hospitalization. Discussion of the presenting complaints, current difficul-
ties, and background provides the basis for development of a problem list.
This problem list may serve as the guide for the entire course of therapy. During
subsequent sessions, specific problems from this list are targeted for therapeutic
intervention.
Explanation o f the Cognitive Model and CBTprocedures. A brief descrip-
tion of the cognitive model of therapy is provided, with the therapist drawing
upon examples from the problem list to establish the relevance of therapy.
The therapist also may ask about the patients' "theory" of depression or their
knowledge about the biomedical model of treatment. This information may
assist the assimilation of the cognitive model with the patients' beliefs about
depression and its treatment.
Reducing hopelessness and suicidality. Most recently hospitalized patients
will have significant thoughts of hopelessness and/or suicidal ideation. The
therapist helps the patient to select an agenda item related to these feelings
for intervention. It is important to demonstrate that use of the therapy can
result in improvement in depressed mode (even transiently) during the initial
session.
Homework. The overall rationale for homework is discussed, leading to an
initial assignment. A typical initial homework assignment includes reading
the pamphlet Coping With Depression. (Beck & Greenburg, 1974) and high-
lighting areas of interest and questions. Other individualized homework as-
signments may be developed, as indicated by the issues addressed in the first
session.
Feedback. The therapist elicits feedback from the patient about the initial
session.
Summary. The therapist summarizes the session and reviews the homework
assignment, making sure that both the rationale is understood and the patient
feels capable of completing the assignment.
Level o f intervention. Following the session, the therapist assesses the pa-
584 THASE & WRIGHT

tient's severity of depression, suicidality/hopelessness, intellectual capacity,

ability to concentrate and remember, and degree of behavioral impairment.
These data guide the therapist's choices of treatment strategies. Patients may
be grouped into three general levels of cognitive and behavioral functioning:
a) Low-level: severe psychomotor retardation, marked hopelessness/suicidality,
severely impaired concentration, and/or virtually no involvement in pleasur-
able activities; b) mid-level: moderate psychomotor retardation and/or im-
paired concentration. Moderate behavioral impairment; and c) high-level: mild
or no psychomotor retardation. Minimal or no problems with concentration.
Mild to moderate behavioral impairment.
The interview style and choice of specific treatment interventions are matched
to the patient's level of functioning. Most hospitalized patients are initially
at the low- or mid-level of functioning. The specific suggestions for the first
week of treatment sessions are primarily tailored to these patients. Behavioral
methods, relatively simple cognitive techniques, and psychoeducation thus are
emphasized. Patients at a higher level of function may be able to work at a
faster pace, such that some may benefit from identifying and testing schematic
themes in the initial sessions of treatment. Regardless of the level of interven-
tion, all sessions contain the following common elements: 1) setting an agenda,
2) homework review, 3) work on agenda items, 4) feedback, 5) homework,
and 6) summary.
Week 1 - Session 2
Agenda. The therapist elicits feedback about the last session as the first item
on the agenda. The remaining agenda items are determined.
Review o f homework. Review of homework is an important component of
every CBT session. If the homework is not done, time in this session may be
devoted to completing at least one aspect of the homework. This helps to es-
tablish the importance of the assignment, as well as the therapist's commit-
ment to seeing the assignments done.
Introducing the importance o f scheduled activity. Review of daily activities
is included on the agenda of the second session for almost all patients. An
activity schedule is filled out for the past 24 hours. A functional relationship
between periods of inactivity and self-reports of low mood or fatigue is ex-
plored. In such cases, the concept of a downward spiral into depression can
be introduced. If the model is understood, the therapist proceeds to elicit other
relevant examples from the patient's life to help to establish the utility of the
model. The therapist suggests that use of distraction, structure, and planned
activities may help to combat the downward spiral. The therapist obtains feed-
back to determine if the patient understands that increased activity is used
as a starting point for working out of an episode of depression. The counter-
point to this notion, i.e., that inactivity may facilitate worsening of depres-
sion, also is discussed. The therapist then describes the use of mastery and
pleasure (M & P) ratings (Beck et al., 1979). Such ratings then are added to
the log from the previous 24-hour period.
Other agenda items. The selection of other agenda items is geared to the
patient's level of functioning. It is important to avoid a "lock step" approach
 INPATIENT COGNITIVE THERAPY PROTOCOL 585

to therapy; the pace of therapy may be advanced for high-level patients to

include the concepts of cognitive distortions and automatic negative thoughts.
Feedback. The therapist elicits further feedback about the session.
Homework. Homework usually consists of the patient completing a log of
the next 24 hours, including M & P ratings. Lower functioning patients may
benefit from one or two structured behavioral assignments designed to increase
activity level or increase pleasurable activities. Higher functioning patients
also may begin with thought recording procedures.
Week 1 - Session 3
Agenda. An agenda for the session is established collaboratively, including
feedback regarding the past session, reexamination of the problem list, and
review of the homework. It may be useful to begin more specific behavioral
methods, such as relaxation training, if anxiety and/or insomnia remain
problematic.
Homework. Problems with homework are addressed in a supportive fashion.
Examination of the past 24-hour activity log may lead to identification of
periods of mood change and/or inactivity, as well the patient's M & P ratings.
Review of the activity log usually will lead to recognition of areas for behavioral
change. The patient's preferred activities are identified for scheduled use during
leisure time. If necessary, the patient is assisted to identify ways in which these
activities can be adapted to the inpatient setting. Activities which seem too
demanding may be broken down into steps to facilitate completion as graded
task assignments. Negative cognitions about symptoms or events also are ex-
plored and can become the primary topics of therapy with high-functioning
patients. These efforts usually result in refinement for homework assignments.
For example, identification of periods of inactivity or diminished pleasure may
lead to better mobilization of the therapeutic resources available in the hos-
pital, such as recreational or occupational therapies.
Illustration and reinforcement o f the cognitive model. The concept of the
downward spiral is expanded to include the relationship between: a) events,
b) thoughts, c) feelings, and d) behavior. The therapist draws upon a relevant
example from the past day. Many higher functioning patients may begin to
keep a diary for recording thoughts and feelings.
Symptom reduction procedures. If strategies such as relaxation training or
thought stopping are selected, sufficient time is budgeted for teaching these
techniques. The methods of Bernstein and Borkovec (1973) are useful for relax-
ation; a supplementary tape often is provided for use as homework. The fol-
lowing is a summary of cognitive interventions for insomnia: a) Take a his-
tory of the sleep disturbance, focusing on average time to fall asleep, number
of awakenings, perceptions of the "depth" of sleep, and the level of fatigue
upon arising; b) identify the patient's prior history of sleep disturbances, ways
of coping with insomnia, and possible areas of poor sleep hygiene (i.e., caffeine
use, evening exercise, or worrying in bed); c) elicit distorted cognitions about
sleep disturbance (e.g., "I'll collapse if I don't get more sleep" or "I can't sleep
at all!"); d) provide a re-attributional context for the sleep disturbance: i) ina-
bility to sleep restfully is a common symptom of depression; ii) poor sleep
586 THASE& WRK;HT

is likely to improve, without specific intervention, along with improvement

of depression; iii) transient insomnia is annoying but not dangerous; and iv)
light sleep at times of stress or danger has adaptive value, e.g., vigilance and
speed of response; e) provide rational alternatives for distorted cognitions:
i) poor sleep does not equal no sleep; ii) light sleep is frequently perceived
(misidentified) as not sleeping; iii) poor sleep is a symptom (i.e., temporary
or changeable); iv) working through this problem without "sleeping pills" will
be a significant accomplishment; v) the therapist will monitor progress in re-
lief of neurovegetative symptoms and initiate additional treatments (i.e., relax-
ation training) if indicated; and f) provide practical suggestions to improve
sleep hygiene.
Other agenda items. As in session 2.
Feedback. The therapist obtains feedback and summarizes the session.
Homework. Homework activities usually include continued use of the ac-
tivity scheduling and M & P ratings. Behavioral tasks are assigned to increase
the level of activity, including a daily period of physical exercise (Simons, Ep-
stein, McGowan, Kupfer, & Robertson, 1985). If relaxation training is being
utilized, time to practice is specified. It is recommended that at least 30 minutes
of homework are devoted to these initial efforts. The therapist also coordinates
homework assignments with the primary nurse to ensure their completion.
Week 1 - Session 4
Agenda setting. The therapist and patient collaboratively develop an agenda,
including feedback about the last session and review of homework. As before,
problems with the homework are immediately dealt with.
Relaxation training (optionaO. If relaxation is being utilized, a major allo-
cation of time (i.e., 20 minutes) is again allocated. The therapist elicits the
patient's rating of the helpfulness of the method. If problems have been en-
countered in using the tape, they may be dealt with by providing additional
relaxation induction directions (Bernstein & Borkovec, 1973).
Application o f the Cognitive Model to an agenda item. Most patients have
interpersonal concerns, self-esteem issues, or life problems that have been in-
cluded on the problem list. An item from the problem list is selected and the
event-thoughts-feelings-behavior paradigm is applied, emphasizing the con-
nection between automatic negative thoughts and corresponding emotional
reactions. It is useful to draw a visual representation of the cognitive model
(Wright & Salmon, 1990). The patient is helped to identify feelings and be-
haviors which are consequences of negative thoughts about the problem area.
The patient is helped to test the accuracy of these thoughts and to consider
possible alternative explanations. The exercise is continued until some relief
in mood and/or reduction in the certainty (i.e., veracity) of the automatic nega-
tive thought is achieved in the session. (These instructions are most applicable
for patients in the mid-level of functioning. Some high-functioning patients
already may have covered this material in the previous session, whereas other
more severely impaired patients may not yet be ready to begin thought
identification and recording.)
Feedback. Feedback is obtained about the session and any uncertainties
 INPATIENT COGNITIVE THERAPY PROTOCOL 587

are clarified. Skepticism or pessimism are dealt with by identification of auto-

matic negative thoughts or predictions of failure. These cognitions may be
reframed as hypotheses for collaborative examination. The patient is encour-
aged to test a negative prediction (e.g., "I can't do that" or "It won't matter")
in a focused homework assignment, utilizing prospectively agreed-upon criteria
for success.
Homework. An appropriate homework assignment is developed based on
the session's material. This usually includes continued use of the activity log,
M & P ratings, and a progressively more complex graded task assignment.
For most low-functioning patients, the assignment to recognize and record
one event-mood-thought scenario is appropriate. If relaxation training is uti-
lized, continued practice is encouraged and the primary nurse is asked to as-
sist with in vivo practice.
Week 1 - Session 5
Agenda. The therapist elicits feedback about the last session and obtains
the patient's subjective evaluation of the first week of treatment. New develop-
ments are incorporated into the plan.
Homework review. The therapist reinforces successes (or close approxima-
tions) and troubleshoots areas of difficulty.
New agenda items. At least two agenda topics are identified for this session
(i.e., continued work on relaxation training, identification of automatic
thoughts, etc.). Example: The concept of automatic negative thoughts is
reviewed, clarifying the difference between thoughts and feelings. If this is
problematic, the therapist may ask the patient to recall their worst example
of sadness, embarrassment, or rejection. These "feelings" are translated into
statements of thoughts. The patient is encouraged to write these feelings and
thoughts onto the Daily Record of Dysfunctional Thoughts sheet (DRD'R,
Young & Beck, 1982). Example: If the patient is having difficulty mastering
relaxation training, the therapist may consider using a paradoxical or tension-
enhancement strategy, identification of thoughts and images associated with
the inability to relax, or music to facilitate a perceptual shift into a more re-
laxed state.
Feedback. Feedback is obtained about the session.
Homework and weekend planning. The likelihood of inactivity and/or par-
tial relapse during the weekend are discussed. The weekend usually represents
the first break in the continuity of dally sessions; expectations may need to
be lowered such that signs of worsening are viewed as an opportunity to col-
lect further evidence of functional relationships between thoughts, feelings,
and behavior. The therapist assists the patient to develop a schedule for the
weekend, including previously enjoyed hobbies and therapeutic tasks.
With the treatment team the therapist also reviews progress, addressing both
areas of success and difficulty. The homework assignments for the weekend
are discussed with the nursing staff. Based on the preceding, alternative inter-
ventions and plans for the second week of treatment are developed. A con-
joint session is held with the patient's social worker and spouse/significant
other to gather further history, provide psychoeducation about CBT, and an-
588 THASE & WRIGHT

swer questions. Readings (Beck & Greenburg, 1974; Burns, 1980) are provided
and, when appropriate, conjoint CBT sessions may be added to the plan.
Week 2. (Sessions 6 - 10)
Overview. Treatment becomes much more individualized during the second
week. Each session, however, still follows a consistent structure and internal
coherence, including: a) agenda, feedback, and homework review; b) focused
work on two or three specific problem areas; and c) summary of session, feed-
back, and homework. The second week of treatment begins with a re-
examination of the problem list. Revision of the list is based on progress and
difficulties which emerged during the first week of therapy. The new goals for
the coming week are collaboratively developed, maintaining realistic expecta-
tions about what can be accomplished. The pace of therapy is dictated by
symptomatic severity and the degree of therapeutic change observed. In our
experience, about one-quarter of the patients will meet criteria for improve-
ment (i.e., a 50°70 reduction in symptoms) after five sessions, while others (e.g.,
approximately one-hal0 will show a more modest reduction in symptoms, and
yet others will report little change (Thase, Bowler, & Harden, submitted). Sug-
gested therapeutic approaches for each circumstance are outlined below.
Significant improvement. These patients have obtained symptom relief, are
no longer suicidal, and are functioning at the highest level; generally more
intense work is planned in week 2 using the cognitive component of the therapy,
with activity scheduling and other behavioral strategies generally receive less
emphasis. More specific attention is devoted to identification of automatic
negative thoughts and consistent use of the full five column DRDT sheet (Young
& Beck, 1982). Active coaching of more affirmative and definitive rational re-
sponses may still be necessary. This method usually takes at least three ses-
sions to become firmly established. If time permits prior to discharge, auto-
matic thoughts are collated by themes in order to introduce the concept of
schema or silent assumptions (Beck et al., 1979). Finally, additional graded
task assignments may be developed to help the patient address remaining life
problem areas.
Patients showing significant improvement usually do not require hospital-
ization after the second week of therapy. Preparation for aftercare thus begins,
and weekend passes are suggested to confirm readiness for discharge.
Moderate improvement. In our experience, this will be the most common
response following completion of the first phase of treatment. More attention
is given to use of cognitive interventions, and the level of residual symptoma-
tology may require continued use of activity scheduling and graded task as-
signments to increase participation in pleasurable activities. It is usually pos-
sible to begin use of the DRDT sheets during the second week of therapy.
Thoughts and feelings elicited within sessions represent the best targets for
early interventions.
Example
Patient: "But everytime I try to talk to her it gets nowhere. The call was
a complete failure (crying). I don't think we'll ever get back together."
 INPATIENT COGNITIVE THERAPY PROTOCOL 589

Therapist: "I can see that you feel very sad about this. Are you up to talking
about your thoughts and feelings about this?"
Patient: (Still tearful.) "Yes, I guess so."
Therapist: "Good. I wrote down several of your thoughts that accompa-
nied the tears . . . . it gets nowhere . . . . complete failure . . . . we'll never
get back t o g e t h e r . . , these are classic examples of what are called automatic
negative thoughts. In particular, they are to be biased or distorted by a pro-
cess called overgeneralization. It appears that, given your history of marital
troubles, you decided that because the telephone conversation with your wife
went poorly your marriage had no hope, and that because your wife seemed
inattentive you would surely end-up divorced. Can you think of any less ex-
treme possibilities?"
Depending on the patient's overall progress and social support, passes usu-
ally are recommended by the week's end. Such outings often are focused on
a specific homework assignment (e.g., going to a movie or to a restaurant with
a spouse), in which recording automatic thoughts may be paired with the
planned activity. It is important, both with the patient and the Treatment Team,
to establish that this is the typical rate of progress. Impatience for more rapid
improvement is dealt with in a nondefensive manner; it may be helpful to point
that antidepressant medications do not work quickly either.
Minimal improvement. Patients who have experienced <20°7o reduction in
symptoms after five sessions require careful re-evaluation, including review
of the problem list, short-term goals, expectations, compliance, and discus-
sions with the Treatment Team. It is important for the therapist to be aware
of his/her own level of demoralization, including recognition of the following
(biased) cognitions: a) "This patient doesn't have depression - it's a person-
ality disorder;" b) "I can't treat this patient's depression with CBT, it's an en-
dogenous (vital or melancholic) syndrome;" or c) "This patient doesn't want
to get better."
We have found Persons' (1989) discussion of management of therapists'
demoralization to be a most helpful aid to supervision. In addition, it is im-
portant to remind therapists that, with respect to nonpsychotic depressions,
there is no evidence that "biological depression" responds poorly to CBT. Data
from both Dallas (Jarrett, Rush, Khatami, & Roffwarg, 1990) and Pittsburgh
(Thase & Simons, in press) suggest that depressions with biological features such
as reduced rapid eye movement sleep latency do not respond poorly to CBT.
Therapist creativity is called upon in supervision to identify possible missing
ingredients in the treatment plan. Particular attention must be given to under-
standing the patient's phenomenological field, i.e., what is it about the pa-
tient's view of self, world, and/or future that may be maintaining depression
or justifies suicidal ideation? Finite steps away from this position are identified
and appropriate interventions implemented. Activity goals may need to be
reduced and focused more specifically on events which, historically, have been
highly reinforcing. The primary nurses may need to increase their involvement
to coach such activities to ensure their completion. Shifting the daily exercise
period to the morning may be helpful to offset diurnal mood variation. Simi-
larly, the therapy appointment may be shifted to the morning for the same
590 THASE & WRIGHT

purpose. In those patients who have not improved sufficiently to warrant a

weekend pass, a weekend activity schedule is carefully developed.
Week 3 (Sessions H - 15)
Overview. The individualized approach outlined in Week 2 continues, with
sessions again following the general pace and structure previously outlined.
The problem list is revised and new goals for the coming week are established.
Those patients are not ready for discharge early in the week will fall into two
general groupings: partially remitted and unimproved. In our experience, one-
half of these patients will improve sufficiently for discharge after 5 - 10 addi-
tional sessions (Thase, Bowler, & Harden, 1991). Common issues for this phase
of therapy are summarized below.
Partial remission. Review of goals and symptoms usually indicates that prog-
ress has been made in some areas but not others. The therapist and patient
discuss what has been helpful about therapy and what strategies have seemed
ineffective. Review of audiotapes of sessions often reveals that apparently
ineffective strategies have been mistimed, misguided, or ineffectively applied.
The therapist revises aspects of the CBT treatment plan with additional input
from the treatment team and primary nurse.
Generally, greater attention will now be devoted to development of rational
responses to automatic negative thoughts (i.e., columns 4 and 5 of the DRDT).
Many patients still have not mastered this aspect of therapy by the start of
the third week. Since a partial remission may indicate either a higher initial
level of severity or persistently high levels of dysfunctional attitudes (Thase,
1990), progress may be expected to be slower. In any case, the therapist assists
the patient to identify and test automatic thoughts and guides the patient's
generalization of these methods from within-session to in vivo application.
Additional suggestions include: a) providing a wrist counter to record pre-
selected automatic negative thoughts; b) providing a card with predetermined
rational responses to intensely troubling automatic negative thoughts; c) en-
couraging the use of memories or anticipated events if "hot" material is not
available for a given session; d) teaching the patient to identify self-defeating
automatic negative thoughts elicited by their own rational responses. These
"second-order" cognitions may be identified in vivo and shown to undercut
the rational responses; e) Example:
Patient: "I've tried to use these rational responses but they don't seem to
have any effect when I'm upset."
Therapist: "Could it be that they just don't ring true?"
Patient: "Yes! Its like I'm trying to lie to myself."
Therapist: "I've heard that response before. Off the record, what do you
think of a therapeutic technique that involves lies or self-deception?"
Patient: "I guess if it w o r k s . . . "
Therapist: "Perhaps. But given your overall beliefs about dishonesty, I
wonder if thoughts about lying to yourself detract from your efforts to cope."
Patient: "I think you're right."
Therapist: "Maybe, but let's look for some evidence that this is happening.
Are you willing to try an experiment?"
 INPATIENT COGNITIVE THERAPY PROTOCOL 591

Patient: "Sure."
Therapist: "Okay. Let's take that example from your homework, where you
recognized some thoughts and feelings about losing your last job."
Patient: (Refers to a DRDT chart) "I was sitting in my room and feeling
more depressed. My automatic thoughts were: "I'm the first person in my family
ever to be fired. I've failed. What would my dad think? I've let everybody down,
as usual. My rational responses were: "Lots o f people get fired from one job
and go on to be s u c c e s s e s . . . " (interrupted).
Therapist: "I'm sorry to interrupt, but as you give those responses, I'd like
you to identify any thoughts or commentary you might have about them. In
other words, what are your automatic responses to these more positive
statements?"
Patient: "I'll try. "Lots o f people get fired from one job and go o n . . . "
(the patient pauses). That's crap. I failed and that's it. 'Lots of people' aren't
me. Okay, moving on, 'I've failed.' My rational responses were: 'I was fired
from one job. I've not failed at everything. There will be other chances. I was
in over my h e a d . . . ' Quit making excuses for yourself. I have failed at several
very important things. I might never get another job as good as that one. I
could have done the job if only I would have tried h a r d e r . . . "
Therapist: "How do you feel right now?"
Patient: "Rotten, like a failure."
Therapist: "Do you see a connection?"
Patient: "Yes. When I try to give rational responses, it just triggers more
critical thoughts."
Therapist'. "I wrote down your negative thoughts about the rational responses
on a new DRDT sheet. If they were completely true, the rational responses
you gave would be rather hollow or even dishonest. However, your thinking
may be so biased by the depression that only the negative feels really true.
Let's use the new DRDT sheet to test the truthfulness o f each o f the rational
responses and your negative replies."
The therapist may introduce new strategies to facilitate development of ob-
jective assessments of life problems, including the use o f role playing, visual-
ization of the therapist's responses to key automatic negative thoughts, or the
prosecutor-defense attorney analogy. In the latter example, the patient is asked
to organize the automatic thoughts into a set o f charges, so that evidence can
be collected, like a prosecutor, to obtain a guilty verdict. Next, the case for
the defense is similarly developed and the patient is asked to examine their
"case" from a more neutral perspective, i.e., like a jury.
Behavioral activities may be either continued or lessened in emphasis. Efforts
to offset the patient's potential impatience or frustration about the slow pace
o f improvement are dealt with supportively. This process often yields addi-
tional "hot" cognitions for use within the session, as described above. As ses-
sion 15 approaches, close attention is given to plans for weekend passes and
anticipated difficulties following discharge. Weekend passes are planned in all
possible cases; most patients will be discharged the following week if the passes
goes well. Such passes should address the level of improvement in areas of
previously impaired functioning, stability o f mood outside of the hospital and
592 THASE & WRIGHT

the ability of the patient to use newly-learned CBT skills in the natural envi-
ronment. Expectations again may need to be tempered; areas of remaining
difficulty which are identified on the passes can provide further material for
sessions during the final week of hospitalization.
Unimproved. Patients who have not improved following two weeks of treat-
ment require careful reevaluation. While, this is hardly time to push the panic
button in outpatient practice, the expense and associated disruption of a
prolonged hospitalization dictates more intensive management. If the patient's
level of severity is high and little objective progress has been made, termina-
tion of CBT in favor of an alternate approach (e.g., pharmacotherapy or ECT)
needs to be considered. Although somatic therapy may be selected in about
15070 of cases (Thase, Bowler, & Harden, submitted), in many cases modified
CBT methods or interventions can be identified. Again review of audiotapes
of several previous sessions may be particularly helpful. Other useful strate-
gies include: a) advancing with the cognitive component of therapy despite
lack of progress with behavioral strategies; b) adding relaxation training (if
not already done); c) increased use of more "active" behavioral interventions
(i.e., role playing, assertiveness training, therapist modeling of behaviors, and
behavioral rehearsal); d) audiotaping sessions for the patient to review prior
to doing homework; e) increasing the focus on unresolved life problems which
may be maintaining hopelessness; f) increased use of alternate techniques such
as distraction, thought stopping, or sadness inoculation to help to shift affec-
tive focus; and g) increased attention to the role of anger in maintaining the
patient's dysphoria, either through use of the cognitive model to address
thoughts associated with angry emotional states or by use of methods to con-
trol inappropriate anger.
Close coordination of these revisions with the treatment team and primary
nurse is essential to prevent demoralization and undercutting of the plan.

Week 4. (Sessions 16 - 20)

The description of this phase of inpatient CBT is the briefest in the manual;
many of the possible outcomes, contingencies, and interventions have been
discussed already. In our experience, less than 10070of all patients treated with
this approach enter the fourth week of therapy without a definite discharge
plan (Thase, Bowler, & Harden, 1991). Those patients who remain unimproved
are now even more strongly considered for alternate treatments, particularly
if significant impairment of activities of daily living or suicidality persists.
It is important for the therapist to help the patient process nonresponse to
CBT in a rational, balanced fashion (Persons, 1989). In such cases, therapy
is faded in intensity as somatic treatment is initiated.
The majority of patients will now be actively preparing for discharge. Ses-
sion 16 is utilized to review progress, review the problem list, and plan the
agenda for the final week of hospitalization, integrating information from the
weekend's passes. Economic pressures may not permit the luxury of sustained
inpatient work addressing revision of core schematic beliefs, particularly once
 I N P A T I E N T COGNITIVE T H E R A P Y PROTOCOL 593

the patient has experienced a significant symptomatic relief. As such efforts

may be most useful when patients have achieved and maintained a significant
response (Young & Beck, 1982), they logically fall within the domain of sub-
sequent outpatient treatment.
Therapeutic work during the final week builds on areas of improvement
and expands to areas of anticipated difficulty after discharge. Of greatest im-
portance, the patient needs to master independent use of the DRDT, achieving
success in reliably reducing the emotional impact of automatic negative
thoughts. The initial work on identification of core silent assumptions or
schema is started by having the patient review past DRDT sheets and organize
the thoughts by themes (i.e., competence or loveability). Writing a brief au-
tobiography also may facilitate this process (Beck et al., 1979). The range of
cognitive interventions may be broadened as well. For example, patients are
encouraged to develop experiments involving interactions with family or
friends.
Preparation for discharge also deals with the following questions:
a) What problems will I encounter when I leave the hospital? What will
"stress" me? b) How am I likely to feel when stressed? c) What are the likely
automatic negative thoughts which accompany my reaction to stress? d) What
have I learned here to cope with these thoughts and emotional reactions? What
are my likely behavioral or rational responses? e) What are my warning signs
for worsening depression?
Potential answers to these questions are addressed during the final sessions
and provide the basis for homework assignments. In addition, long-term goals
may be identified and operationalized. Accurate assessment of deficits which
may diminish the likelihood of successful goal attainment and of realistic plans
to address these deficits are developed. For example, job dissatisfaction may
be related to inadequate training or insufficient education for a more desir-
able line of work. Historical review often reveals very real situations which
led to underemployment, such as an unplanned pregnancy, family difficulties,
or an unrecognized episode of depression earlier in life. Nevertheless, revi-
sionist understandings do not remedy skill deficits, and consultation with the
hospital's vocational rehabilitation service is useful in such cases.
Saying goodbye to staff and patients represents a final task prior to discharge.
Because of the intensity of the inpatient experience, such termination may
be difficult, particularly when automatic negative thoughts regarding issues
of friendship, dependency, desertion, and responsibility for the well-being of
others are activated. Although such reactions usually are time-limited, they
may be dealt with in the closing sessions of therapy if significant dysphoria
is associated.
Based on our initial year's experience with the Pittsburgh inpatient CBT
program (Thase, Bowler, & Harden, 1991; Thase & Beck, in press), we no longer
offer the inpatient treatment unless outpatient continuation treatment with
CBT is planned. Whenever possible, we recommend continued treatment with
the same therapist, with the first outpatient session scheduled within four days
of discharge.
594 THASE & WRIGHT

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RECEtVED: January 3, 1991

ACCEPTED: June 21, 1991