I was once lost in Istanbul. A kindly man came over, smiled at me and asked: “Can I help me?” Okay, so English wasn’t his first language and he meant ‘you’ not ‘me’, but it got me thinking. How do we know where we are going, how soon we’ll arrive, when we’ve arrived? And what’s this got to do with top quality psychotherapy?
When you ask someone for directions:
- you don’t spend hours talking about all the places you don’t want to go.
- you want step by step instructions on how to get there (some people – the best kind of direction givers) may even lead you there.
- you need to know how you’ll know when you’ve arrived (“you’ll see an enormous mosque by the railway”).
- it can be useful to know what indicators along the way will let you know you’re getting close (“the spice market will be on your left, the Galata Bridge on your right”).
- and when you’ve arrived at your destination you should have a much better idea how to get back there again in future, on your own if needs be.
Depression is a strange city
And it’s exactly the same when treating people for depression. A depressed person is essentially a stressed person. Long term stress stops us thinking strategically, sequentially and logically. (1) Just you try finding your way in a strange city when you’re pumped up to the eyeballs with stress hormone and you’ll see the truth of this.
Depressed people need empathy, sympathy and understanding for where they are now, certainly. But they also need direction. They may want (and need) to talk about all the places they don’t want to be, or to go back to, but effective therapy for depression is about so much more than that. (2)
Just like anyone trying to find their way, a depressed persons needs to develop an ongoing sense of where they are going, how they’ll get there and what ‘markers’ of progress to look out for. Once they’ve arrived at their non-depressed, happier destination, they’ll need to know how to get back there again if need be. That’s why I use these psychotherapy techniques.
Four ways you can help your depressed clients with directions
1. Establish clear goals
A depressed client may (quite naturally) want to tell you all about their depression, but to really begin working with them you’ll need to discover where they actually want to go in positive terms.
Ask questions like:
“Okay, so how are we going to know when you’ve left that depression behind you?”
They might reply in the negative:
“I won’t be so miserable all the time.”
“Okay, so what will be there instead of misery?”
Get the person to vividly describe in positive terms exactly how they’ll know the depression is gone.
2. Break down all or nothing thinking
When people are depressed they are more emotional. The emotional brain has us thinking in very all-or-nothing terms:
- “I am completely ruined”
- “Nothing good ever happens to me”
- “People always let you down.”
One thing I’ll do early on is describe how depression seduces people into oversimplified negative thought. I’ll ask people to notice this in themselves and challenge it (“If you see the Grand Bazaar you’re going the wrong way!”)
I might say:
“As you begin to leave that depression behind you’ll start to notice how your thinking becomes less extremist…”
Depression thrives on black and white thinking. A clear sign that people are coming out of depression is that they’ll be doing less black and white thinking.
3. Grade the depression
Depression can be a scary beast. Because depression has us using less of the strategic ‘left brain’, encouraging a depressed person to be more strategic can help their mood. Asking someone to grade the severity of the depression on a scale helps them to:
- break down black and white thinking
- notice improvements.
So you ask them:
“If one is the most depressed it’s possible to be and ten is the happiest, where are you right now, would you say?”
“I’d say I was a three.”
Now, rather than just ‘completely depressed’, we’ve got a ‘3’. You might begin to break down the depression even further by asking:
“What stops you being a two, or a one?”
The answer may give you clues as to what they need more of in their life.
Or you can go in the other direction:
“What do you suppose will be different when you’re at a five?”
4. Check the roadmap for avoiding depression in future
Toward the end of therapy it’s important to check that they know how to ensure they stay out of depression in the future. Relapse rates for depression are much lower in people who have received effective psychotherapy rather than just drug treatment. (3) You might ask:
“Okay, so from what you know and have learned, what active steps will you take in future to avoid getting the way you were again?”
The depressed mind feels lost and directionless; a good therapist will act as the friendly, knowledgeable guide – because we can all feel lost in a strange land sometimes.
- Decreased prefrontal cortex activity at rest, especially on the left side is a consistent with (brain imaging) findings in depression. The severity of depression is often related to the degree of frontal hypometabolism. Several studies have indicated that the hypometabolism normalizes after treatment if the patient’s mood improved. When depressed patients perform a concentration task the left prefrontal cortex often activates to normal levels with the effect of improving their mood. Dwelling on problems has the effect of lowering left brain pre-frontal activation and lowering mood. S. Lui, L. M. Parkes, X. Huang, K. Zou, R. C. K. Chan, H. Yang, L. Zou, D. Li, H. Tang, T. Zhang, et al. ‘Depressive Disorders: Focally Altered Cerebral Perfusion Measured with Arterial Spin-labeling MR Imaging’.Radiology, May1,2009; 251(2): 476 – 484.
- Antonuccio, Danton and DeNelsky’s meta-analysis of more than 100,000 studies of depression treatment (‘Depression: Psychotherapy is the best medicine’) found that so-called ‘insight therapy’ (which merely looks at what went wrong) has a poorer outcome for depressed people than no therapy.
- See Antonuccio, Danton and DeNelsky, as above.
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