Depression is probably the most common complaint that psychotherapists encounter. In the United States approximately 17% of people will be affected by depression sometime during their lifetime, with roughly 9% of females and 4% of males reporting a major depressive episode in any given year. Since individual experiences with depression vary in intensity and origin, it may be worthwhile to survey a number of ways of treating this widespread impediment to mental health.
My own experience in my late teens and as a young adult with the North American medical system’s response to depression is probably similar to that of many others. My HMO (health maintenance organization) sent me to a psychiatrist who listened to my complaint and wrote a prescription. When I said I didn’t want to take a medication he seemed incredulous. “You’re depressed.” he said. “We give you pills.” Happily, I was able to get a referral to a psychotherapist who helped me to understand the underlying causes of my affliction and discover ways of dealing with them.
Since health care plans typically cover psychiatrists but not psychotherapists, we therapists often encounter clients who are already on medication but who resist the idea of remaining on medication for the rest of their lives. Psychotherapists, of course, are not qualified to prescribe medication, but it may be appropriate to offer two observations here. In the first place, medication may be essential in order to bring a client to the point that psychotherapy can even be undertaken. In the second place, clients who complain about the side effects of their particular medication should be told about the wealth of pharmacological interventions available to them. If one medication proves unsuitable, their physician should be able to suggest a satisfactory alternative.
An Adlerian Approach
Administering the Beck Depression Inventory can establish a baseline against which to measure future progress. Asking the client to report a subjective level of depression, on a scale from 0 to 10, provides an easy way to record changes week by week. Occasionally a “severe” level on the Beck Inventory will accompany a subjective report of 3 or 4, suggesting a long-term habituation to the depressed state.
For homework a client may be asked to maintain a daily Depression Record requiring the client, every hour on the hour, to make a note of what he or she is doing at that time. The client then rates each activity on a scale from 0 to 10 for Pleasure and 0 to 10 for Mastery (asking whether the client experiences a sense of accomplishment in that particularly activity). Both pleasure and mastery compete with depression. Clients are asked to reflect how their activities influence their moods. Are there things that make them feel better or worse?
Activity is a basic first response to any form of depression. In extreme cases, getting out of bed may be considered a major triumph. Clients are asked to monitor and report their activities: are they bathing or brushing their teeth? Are they engaging in some activity, such as walking, that takes them out of the house? Each week clients are asked to rate their level of functioning, on a scale from 0 to 100, and encouraged to aim for improvement each week. The therapist can assist clients in identifying obstacles to activity, such as relationship problems, self-esteem issues, etc.
In-depth treatment of depression often involves exploring what Adlerians call Life Style, or core beliefs, and teaching clients how to use a T-Chart. At the top of the page the client writes a brief description of a difficult experience. In the left column the client gives full rein to an emotional response—what we call “writing the rant.” This part of the exercise engages only the “emotional brain.” The client is instructed not to criticize, not to analyze, and not to solve, but simply to write out feelings, as if taking dictation from the client’s “inner child.” When all the emotions have been expressed, the client does some deep breathing to open the pathway to the neo-cortex.
The right-hand column provides a forum for the “rational brain.” Here clients imagine what they might say to a good friend who expressed the sentiments contained in the emotional rant. The right-hand column contains the wisdom of the most mature aspect of the person (e.g., “Big Fred”), soothing and comforting “Little Fred,” the person’s inner emotional child. In the session, the therapist may suggest possible new ways of thinking about the issue and invite clients to develop their favorites. In this way clients learn to reframe negative core beliefs.
Recent developments in brain science have helped us to understand how repetition of a behavior or thought pattern strengthens and enlarges the associated neural pathways and, conversely, how stopping a particular behavior or thought pattern weakens and reduces these pathways. The experience of depression often follows a pattern of depressive thoughts leading to a depressed state. Stopping those thoughts before they take control may allow one to interrupt and alter the pattern.
I describe my own experience of depression in terms of a gentle slope leading to a rusty tank partially filled with tepid water. It’s a familiar spot and not uncomfortable. With some effort you could pull yourself out of the tank, but why bother? During my early adult years I associated depression with inevitability and helplessness: depressed thoughts would carry me down the slippery slope giving me no choice but to wait until the mood eventually lifted.
Mindfulness offers clients an alternative to being helpless victims of depression. I liken the process to the procedure of self-arrest that a mountain climber employs to stop sliding down a glacier. The climber buries the tip of an ice axe in the snow, bringing the slide to a halt and offering an opportunity to regain one’s footing. I particularly admire this metaphor for its image of powerful physical exertion in contrast to the depressed person’s usual habit of passive inaction.
I encourage clients to put together a “first aid kit” of activities to counter the slide toward depression. Naturally each person’s list will be different but I offer mine as an illustration: take a walk; go for a run; listen to a favorite piece of music; eat ice cream; eat chocolate; go to a movie; call a friend; visit a friend; read something funny. I encourage clients to persist until they have extended the list to a dozen items, the idea being that if one activity doesn’t particularly appeal, another may. In every case, the goal is to arrest the descent into the depressed state. Each time you succeed in this kind of “self-arrest,” the mental pathway leading to depression becomes weaker.
The key to this approach is self-awareness, or mindfulness, which is usually developed through the practice of meditation. You need to be aware the moment you lose your sense of mental balance, or centeredness. Clients who lack this kind of internal gyroscope may profit from the exercises described in The Mindful Way through Depression.
EMDR (Eye Movement Desensitization and Reprocessing) has become recognized, through thirty-plus years of clinical research, as the treatment of choice in dealing with post-traumatic stress disorder. In addition to addressing the so-called “capital T” traumas associated with PTSD, EMDR has proven useful in treating the “small t” traumas that often lie at the root of depression. Depression often arises from anger displaced from its proper target and directed against oneself, or from situations of learned helplessness, or from prolonged grieving, be it in response to a physical death or in reaction to a virtual death such as loss of social standing or loss of a job. Any of these conditions may fall into the category of trauma, understood as any experience that overwhelms our capacity to deal with it. It is not surprising that such trauma often occurs in childhood, since children notably lack the ability to deal with overwhelming emotion.
Using the EMDR protocol to process hitherto unprocessed traumatic experiences often has the effect of removing the impetus toward depression. Accompanying EMDR treatment with exercises in self-awareness may disrupt the pattern of depression without ever involving the client in specific “depression therapy.”
The stories we tell about ourselves not only reveal our core beliefs but also provide a means of altering those beliefs. Narrative therapy begins by listening to a client’s story and then offering a framework for retelling the story in such a way that the problem becomes objectified. Instead of being the problem, the client considers being in relationship with the problem. This subtle shift of perspective has great potential power. The client stops being “a depressed person” and instead sees him- or herself as someone beset by depression, looking upon depression as an external enemy.
The narrative therapist asks clients to identify occasions in which they succeeded in resisting or thwarting the enemy depression. Even a single such success may suffice to support a view of depression as an opponent who often wins but not invariably. Seeing the problem as separate from the person helps to overcome the passivity often associated with depression and enables the client to see the possibility of taking charge, and resisting or overcoming the problem. Learning to tell better stories accompanies learning to take responsibility and increasing one’s sense of self-worth.
The perspectives described here hardly exhaust the techniques for dealing successfully with depression, but may encourage therapists to widen their view of how to treat this most common complaint.
Adler, Alfred (1956). The Individual Psychology of Alfred Adler: A Systematic Presentation in Selections From His Writings. New York: Harper & Row.
Eron, Joseph B. and Lund, Thomas W. (1996). Narrative Solutions in Brief Therapy. New York: The Guilford Press.
Freedman, Jill and Combs, Gene (1996). Narrative Therapy: The Social Construction of Preferred Realities. New York: W. W. Norton.
Shapiro, Francine (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. 2nd edition. New York: The Guilford Press.
Shapiro, Francine and Forrest, Margot Silk (2004). Eye Movement Desensitization and Reprocessing: the Breakthrough “Eye Movement” Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books.
Williams, Mark et al (2007). The Mindful Way Though Depression: Freeing Yourself from Chronic Unhappiness. New York: The Guilford Press.
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