I co-facilitate a depression group with a counsellor/social worker about 20 years my senior who has thought deeply on the the topic of depression. He often challenges clients with the statement
We “follow” a widely used psycho-educational CBT-based manualized program . We start light on the topics of : goal-planning, stress, diet, exercise, and nutrition. We encourage people to make SMART goals with their small successes as stepping stones to easing out of depression. The manual also looks at social engagement, fun activities, assertiveness, and also negative thinking patterns. Basically it looks at the whole of a person’s life that is affected by depression and works to gain understanding into how altering behavior and thinking, even in small ways, can improve mood and decrease depression.
This is all fine and wonderful. However this manual only dedicates about one session (if that) on core beliefs. My co-facilitator thinks that depression is at its core about a couple main themes.
2. Worthlessness and
Firstly, based on his model he sees a big problem with targeting the externals (social activities, exercise, etc.) as a real effective change agent for depression.
As a person with depression at their core thinks they are worthless, hopeless and deserve to be alone even small successes of changing diet or exercise likely do not help in the long-term. For example, someone starts to do well walking everyday, but still feels depressed. We say “Fred great work, look you accomplished what you haven’t been able to do in 10 years”. He then thinks “Oh God, I feel even worse, I must be really depressed, I should be feeling happy but I can’t even get better when I follow this program”. When we solely focus on the externals of someone’s life, even their negative thinking about events or triggers, the core beliefs may persist.
This is of course classic CBT, but often we as therapist may stay on the surface for some time or look solely at the environment or triggers or be quick to offer realistic core beliefs that a client “should” instead of staying and delving into the darker beliefs that sustain an individual’s depression and allowing the person themselves to acknowledge and desire alternative ways of seeing themselves.
My colleague insists that to begin to effectively treat depression we must start to acknowledge the true thoughts and beliefs that are plaguing the person. For example, an honest statement to really get going on therapy would be : “I’m making all of these goals and getting out and being social, but I still don’t feel good, I really believe that I should be alone, that I don’t deserve to have friends”. In a trusting therapeutic context we process that and then work forward and life improvements.
One thing that he says is that “Nobody wants to be here” [in therapy]. Most of us therapists find it hard to believe. In saying this he means that the nature of the depression, while they are still depressed is that honestly most people find being in therapy further confirms their worthlessness.
Of course I like to think that people both do not want to be in therapy and also want to because the therapeutic relationship itself is an avenue of hope as they learn to act out and learn positive regard and new ways of relating that bring life instead of darkness and depression. That having someone caring, yet challenging in their life is something people find incredibly difficulty but also crave.
Clients with depression carry a heavy burden, many have suffered a large part of their life. They are experts in understanding themselves; what we can bring is empathy, acknowledgement of the depth of their pain and darkness, faithfulness, and a keen balance of questions and encouragement that can help them find their way to a more realistic view of themselves and the world.
What are your experiences with therapy for depression?
What has worked? What hasn’t?