“It’s a soul-crushing hellhole. I feel glued down by it. I can see people outside having a life, laughing and loving, and that makes it worse. For me it’s all hopeless, useless and pointless. It’s like I’m destined for a miserable kind of annihilation. I feel lethargic and terrified at the same time. I might look okay but on the inside I’m screaming!”
That’s how Kathy, a client, described her depression during her first session.
In this piece I’m going to give you two CBT techniques for depression, which are closely related under the ‘cognitive reframes’ umbrella. The first actually works quite unconsciously for the client, while the second helps educate the conscious mind in new, more flexible thought patterns. Together these two techniques can have major benefits for depressed clients.
One thing is for sure. More of us need to know how to effectively treat depression than ever before.
The depressed generation
Depression is ravaging the modern world. It’s life-sapping impact is felt by hundreds of millions and it’s now recognized as the number one disorder of modern life. According to the World Health Organization, 300 million people are affected by depression at any one time. But the current depression stats get even more depressing.
What’s happening to our young?
Depression is striking increasingly younger people, even children. Many more teens are now regularly consuming antidepressants. The proportion of people becoming depressed is now ten times greater than in 1945!. Depression is on the rise in all age groups, but mostly in the young.
It seems there is something about our lives now that is causing widespread harm. We, you and I, need to help stem the tide so that future generations are healthier and happier.
Cognitive Behavioural Therapy (CBT) has long been seen as a useful tool in helping lift depression. But weirdly, its reputation seems to be sinking.
CBT is only half as effective as it used to be
Through a meta-analysis of 70 studies between 1977 and 2014, psychological researchers Tom Johnsen and Oddgeir Friborg drew a strange conclusion: Cognitive Behavioral Therapy is now around half as effective in treating depression as it used to be.
This may make sense in the context that depression thrives on negative rumination and expectation. In the early days of CBT, depression sufferers would have likely had high hopes for its effectiveness. But as the novelty of CBT has worn off and reports have emerged questioning its effectiveness, the positive expectation (placebo effect) may have fallen away a bit.
Half of CBT’s initial effectiveness in the treatment of depression may have been purely due to the sense of hope it generated in those being treated. Hope is an antidote to depression, perhaps the most powerful antidepressant of all. Knowing how to generate hope in depressed clients is a vital therapeutic skill.
So even among people prone to rumination or misuse of the imagination, the usual depressing effects of rumination can be mitigated when they ruminate with hope.
I’ve written about what we really have to include when treating any depressed person. I’ve also written about the limitations of the Cognitive Behavioural model. But I’ll just reiterate briefly why the use of CBT in isolation can never successfully treat emotional problems.
Putting the cart before the horse
The crux of the problem with some CBT-based approaches is that strong emotion most often arises not after we have thoughts, but before. Thoughts are more often a reflection of feelings (especially powerful feelings) than a cause of them.
So it’s more effective to change feelings in order to change thoughts than the other way around.
That’s not to say that changing thoughts can’t change feelings, but when the emotions are powerful, our clients can feel swamped. It can be hard to think anything when we are caught in the frenzied grip of intense feelings.
To put it metaphorically, how can we expect to clear scattered leaves when the wind is still whipping them about?
The whipping winds of the psyche
You can sweep your pathway until kingdom come, but if the wind won’t let up the leaves will only come swirling back. When the wind (excuse my heavy-handed use of metaphor!) dies down and all is calm… that’s when we can get everything in order.
When the mind is calm, then we can examine and widen the context of thinking.
There are more neural connections leading from the emotional centres of the brain to the cognitive centres than vice versa. We know this from the research of neuroscientists such as Joseph E. LeDoux.
This basic tenet of neuroscience contradicts the principles of classical CBT (though, to be fair, many CBT practitioners are incorporating mindfulness and clinical hypnosis into their practice).
We must always remember that when feelings are powerful, as they certainly are in depression, we need to work to calm those feelings first and foremost. But once the mind is sufficiently calm, then we have a chance to help the depressed client widen their context by seeing reality above and beyond the usual depressive thinking biases.
Then, and only then, we can help the client get into the habit of generating non-depressing causes for life events, and therefore thinking differently. And this will have an impact on emotions.
So how does an effective CBT technique actually work?
It depends on how you see it
Whenever we help a depressed client view their reality differently we are applying a therapeutic reframe. In a sense all CBT techniques can work as reframes. But it’s vital to understand something about reframes:
They’re not just cognitive.
A reframe happens as an experience in the client’s mind. It’s not simply a matter of logical deduction or reasoning. The client needs to feel as well as think that the new way of seeing is more true than the old depressing way.
We need to know how to deliver reframes with emotional impact, but of course we also need to ensure they make perfect logical sense.
Always bear in mind that:
- Trying to change thoughts while strong emotions still dictate those thoughts may not work.
- We may need to change a client’s emotional state before widening their cognitive context through a reframe.
- We need to deliver the cognitive reframe in such a way that it appeals directly to feelings as much as thoughts.
Beliefs are powerful. Some people are prepared to die for their beliefs. Depressed people hold very strong, emotionally driven beliefs (as to how bad things/they/others are). The more we directly oppose someone’s strong beliefs, the more they will tend to protect and cling to them, even when those beliefs damage them. With this in mind, I like to use CBT techniques subtly.
Don’t use a spray gun when a paintbrush will do
We need never ask a client, “Why don’t you look at it like this?” Trying to force people to see something a different way can trigger the rubber band effect, in which the tension of being pulled one way increases the desire to move fast in the opposite direction, no matter how well-intentioned the intervention.
It has been found, though, that simply asking questions can be a wonderful way of helping people discover new ways of seeing for themselves, as with Socratic questioning.
CBT Technique for Depression 1: Use reflective reframing
It’s important to feed back what a client has said to us, both to check our understanding and also to build and maintain rapport. But don’t forget that your depressed client is giving you not only factual information but also emotional information. They will be describing and explaining to you how they see things using their own explanatory styles. And this gives you a window into their way of thinking.
As a recap, an explanatory style is the way a person explains situations and events to themselves. Depressed people tend to:
1. Globalize negativity
The bad event is specific but to the depressed person “everything is ruined!”
- “I failed my maths test… my life is crap!”
- “She wouldn’t go out with me… nobody likes me!”
- “My relationship ended… nothing ever goes right!”
One situation or event is extrapolated to cover all situations or events. This thinking style is often driven by feeling hopeless. As with all thinking styles, it can also be picked up from others.
2. Internalize negativity
The cause of the bad event is assumed to be mainly or entirely due to the depressed person’s core identity. Possible external causes for the negative event are minimized or remain entirely unperceived.
- “My marriage ended… I screw everything up!”
- “Why does it always happen to me?!”
- “They seem in a bad mood; it must be because of something I’ve done!”
- “This is just my luck!”
(Conversely, it is also common for depressed people to overly externalize the causes of their misfortune, exaggerating the role of others and therefore blaming them. This is depressing because it entails lack of control, and feeling powerless is depressing.)
3. Stabilize negatives
Bad things are seen as permanent or stable.
- “Nothing has ever worked out for me!”
- “I will never get better!”
- “It’s always the same!”
Positive parts of life, on the other hand, are seen as temporary and fragile, “too good to last.”
These emotionally driven classic depressive thinking styles can be quite entrenched. Rather than trying to argue a client out of using them, we can be subtle and simply feed back to the client the heart of what they’ve said using a non-depressive explanatory style. In this way, cognitive reframing can be not just subtle but even unconscious.
We are showing them, not telling them.
The client will know that the way you feed back what they’ve told you is different somehow, but this may not even be at a conscious level.
Client: “My whole [global] life is just a total [global] mess!”
You: “So you haven’t yet [non-stable] got the things [specific] you need from life.”
We have fed back the heart of what they have said but in such a way that we are time-limiting the misery and implying more specificity as regards their dissatisfactions.
Client: “Nothing [global] ever [stable] works out for me. I [internal] screw up everything [global]!”
You: “What are the things [specific] that haven’t worked out [past tense so non-stable]? What [specific] have your mistakes been [non-stable]?”
Client: “My life [global, stable] is just totally unbearable!”
You: “What [specific] are the worst things about your life at the moment [time-limited so non-stable]?”
We are starting to reframe depressive thoughts in a way that isn’t forced or obvious. We are not arguing with the client’s perceptions, simply widening the context a little bit at a time.
Next we can start to work more directly with their conscious understanding of how depressive thinking has been blighting them.
CBT Technique for Depression 2: Describe the pattern of depressive thought
Once your client has had the opportunity to feel the moderating effects of the way you feed back what they are telling you on their depressive thinking (and this can be done partly through Socratic questioning), you can then help them examine the nature of depressive thinking on a more conscious level.
We can help our client:
- See their pattern of depressive thought bias ‘from the outside’, and therefore see that it is a way of perceiving reality, not just how things are in reality.
- Start to recognize all-or-nothing, ‘extremist’ thinking in themselves and start to generate more flexible thought.
Rather than saying, “You are prone to depressive thinking. Your explanatory styles are depressing!”, we can again be more subtle: “Many people going through depression find they think in very specific ways…”
You can then describe the depressive explanatory styles (global/internal/stable for bad things; specific/external/unstable for good events). You may find your client nodding. You might say: “Does any of this sound familiar to the way you have been seeing things?”
It can be a massive relief for depressed clients to actually see some of the patterns of what they have been doing. It puts a fence around the whole experience.
We can then give them tasks to start spotting within themselves when they are using depressive thinking.
Of course, simply looking at a client’s cognition never constitutes a complete treatment for depression. We need to look for any signs of trauma that may have been locking the depression in place, and deal with it if necessary.
We need to look at how the client is living now and how well their primal emotional needs are met, and help them meet those needs better. This will include encouraging them to behave in ways that help them switch off emotional loops (intrinsically satisfying tasks with beginnings, middles and ends) and minimize inward focus and rumination, the fuels of depression.
We need to look at the connection between sleep and depression, and help them understand the role of over-dreaming in the onset and maintenance of depression.
But within my comprehensive depression treatment approach, I always use these two CBT techniques as really helpful tools.
Remember Kathy from the start of this piece? In our fifth session, she said:
“I am now seeing that the way I was looking at life was just that… a way of looking. But not how life actually is, or ever need be again.”
Music to my ears.
And you can learn more about rapid treatment for depression with our online course How to Lift Depression Fast.
- Danton, W., Antonuccio, D. and DeNelsky, G. (1995), Depression: Psychotherapy is the best medicine. Professional Psychology Research and Practice, 26, 574. The authors conduct a meta-analysis of over 100,000 pieces of research from 1978 to 1993 on the causes, consequences, and best treatments for clinical depression.
- See the research cited in Martin Seligman’s wonderful book Learned Optimism: How to Change Your Mind and Your Life.
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