The Psychological Treatment of Depression

J. Mark G. Williams

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134917730
• Edition: 2
• Topic: Psicología
• Subtopic: Salud mental en psicología

'A clear, rigorous account of cognitive behavioural methods for treating depression.' - British Journal of Psychiatry
The use of behavioural and cognitive techniques for treating depression has yielded exciting results. Cognitive Behaviour Therapy (CBT) is as effective in the short term as anti-depressant drugs and has longer-lasting effects than medication. This book brings together assessment and treatment techniques of proven efficacy, describing them in usable detail and setting them in the context of current psychological theories of depression. It is an invaluable guide to practitioners wishing to make use of CBT.

Chapter 1

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Introduction

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A man was walking in the hills when he fell down a disused mineshaft. He fell fifteen feet, then became wedged. He dare not move lest he fall further. He cried out for help. Eventually another walker heard his cries. This walker was something of an expert at rock-climbing, pot-holing and generally getting out of fixes. Instructions were shouted down the mineshaft—where to put feet, hands and body to get into the correct position for climbing out But the man wouldn’t move. The walker muttered something about getting more help, and moved off. After some time a second walker heard the cries and came to help. This walker instantly recognized the man’s distress and confusion. He realized that the man did not have the courage to move while feeling so hopeless about his situation. So he gave him reassurance, put him at his ease, made him feel better. The man did feel better, but he was still in the mineshaft. He did not move. So the second rescuer went away to fetch more help.

Eventually a third walker arrived on the scene. Like the first, he had rock-climbing experience. Like the second, he realized that the man would not make any move whilst he was so upset. Furthermore he knew two things: that the man in the mineshaft was unlikely to take the rescuer’s word for it that moving in a certain way would not make matters even worse; second, that from the top of the mineshaft it was impossible to know precisely what the man’s position was, what the risks were of moving. He would first have to ask the man to make small movements (which from experience needed to be of minimal risk) and then to ask for a report on their effects. As victim and rescuer gathered more information, the victim’s courage returned. Slowly he moved, took more risks. In time he was free. End of parable.

Depression is a little like the disused mine shaft. Everyone becomes a little depressed from time to time. But sometimes, the depth of depression outweighs a person’s abilities to cope. Mood spirals downwards, the person experiences hopelessness and despair, and almost total emptiness, feels unmotivated to do many of the things they used to find enjoyable, or feels that they would rather not meet other people. It is no accident that the metaphors we used to describe increasing severity of depression speak of ‘depth’ or ‘spiralling downwards’. Whereas anxiety ‘rises’, depression ‘deepens’. Hence the parable. The severely depressed person finds themselves trapped, in darkness, not daring to make any move for fear of making things worse, helpless about their prospect of escape.

The story captures what is important about structured psychotherapies. They are not mere techniques telling a person how to get out of a bad situation, able to be taught mechanically. Neither are they merely offering a safe relationship. They aim to provide a careful combination of the two. The ‘skilled rescuer’ is the one who is able both to teach the specific things which it will be necessary for the trapped person to do in order to climb out, and to forge a relationship with the person which will give them the courage to try after so much has failed. Of course, a therapist’s personality may occasionally be sufficient so long as the person already has the necessary skills to cope with difficulty. Indeed, this may be why some placebo therapies sometimes work quite well, by encouraging those who normally use active problem-solving strategies to mobilize their skills. But for some people, dealing with their difficulties has exceeded their capacity. In this case sheer force of personality of a therapist will not be sufficient.

The value of individual structured psychotherapies for depression, of which the best known are social skills training (Hersen et al., 1984; Sanchez et al., 1980), interpersonal psychotherapy (Klerman et al., 1984) and cognitive-behaviour therapy (Beck et al., 1979) is that they provide information and specific exercises for depressed patients who find they have fallen into the depths. This book describes a range of techniques. The techniques are focused around one of these psychotherapies, cognitive-behaviour therapy, but many (e.g. task assignment) are common to all structured psychotherapies.

Although much of the book is concerned with ‘techniques’, the parable reminds us that these need to be embedded in a supportive relationship. Techniques are not mere mechanical devices in which certain wheels can be turned and certain responses produced. A.T.Beck and his colleagues, who have brought together many of the techniques to be described in this book under the heading of cognitive therapy, have also emphasized the qualities of empathy, warmth, genuineness and unconditional positive regard in the therapist. Appropriate and delicate use of humour, challenge, sympathy and encouragement are fundamental. Yet the research evidence suggests that the quality of the relationship is not sufficient for therapeutic progress. Studies of unstructured psychotherapy for major depression have been disappointing (see Whitehead, 1979; DeRubeis and Hollon, 1981). Furthermore if one systematically varies the subcomponents of treatment within a single session (for example, by simply exploring a negative thought, versus collaborating to challenge its validity), differences in depressed mood can be detected, despite the factor of the relationship with therapist remaining constant (Teasdale and Fennell, 1982).

No book can help much in developing the personal qualities of accurate empathy into which therapists will need to embed their techniques. However, knowledge of strategies for assessing and coping with depression can help the therapist by giving him or her a clarity of perception which may better withstand the tendency to become so drawn in to the hopelessness of the patient that the therapist ends up feeling only despair and pessimism for the patient. For this reason, the techniques of assessment and of behavioural and cognitive intervention form the central aspect of this book. Exercises to use in further training, including a checklist to help evaluate one’s own developing competency as a therapist will be found in Chapter Nine.

Knowledge of the techniques themselves is not sufficient. For unless a therapist has an overall framework from which the techniques are derived, they will not know in which direction to go if one approach is not proving helpful. For example, if task assignment is being used by the patient, it is important to know in what framework it is being used. Is it being used to increase the number of pleasant activities; or to increase their enjoyability (a reinforcement theory of depression); or as a homework assignment to learn social skills (a social skills framework)? Or is it being used to discover what undermining images and thoughts occur to the person when they try to engage in activities (a cognitive framework)? At different times in therapy, this same technique may serve any or all of these purposes. Without having the framework clear, the therapist is unlikely to communicate successfully to the patient what is the purpose of the assignment. Worse, the therapist will be unclear how to review the homework at the next session. If the homework has not been performed (as often happens) it makes a great difference which framework was guiding the assignment. Only on this basis can the therapist decide what the next move in therapy may be. For this reason, the next two chapters will focus on the psychological models or frameworks which underlie behavioural and cognitive approaches to depression, and the final chapters will pursue the cognitive model in greater depth. The first requirement of anyone who seeks to treat depressed patients is to know a lot about depression. It will be very important early on in therapy to allow the patient to ask questions and to be able to give answers about what depression is. I will therefore start by summarizing some of the major facts and figures about depression.

SO WHAT IS DEPRESSION?

People become depressed for many reasons, for varying lengths of time to varying degrees. When depressed, different people have various ways of coping. At any one time, 4–5 per cent of a population meet the criteria (detailed below) for clinical depression (Paykel, 1989). In any one year approximately one in ten of the population will have an episode of depression (Amenson and Lewinsohn, 1981). Yet most people cope without seeking treatment. Twenty-five per cent of episodes of depression last less than a month; a further 50 per cent recover in less than three months. For some, the depression may simply pass without their having to do anything. Others will have used a range of different self-help strategies (Parker and Brown, 1979; Rippere, 1977).

We have already noted that 4–5 per cent of the population is depressed at any one time, but in order to give such a figure, we need to have defined clearly what we mean by ‘depressed’. The term ‘depression’ is used very often in our day-by-day conversation to describe a normal downswing of mood. Such downswings in mood may be adaptive. In rather the same way that normal anxiety and fear can warn of danger and prevent more serious harm, so depression may remind of losses and spur a person to find ways of re-engaging with activities or friends. But just as anxiety can become abnormally generalized and severe, so depression can present for the person more problems than it solves. Although the distinction is probably one of degree rather than of kind, what happens when the depression deepens is that more symptoms are ‘drawn in’. The result is clinical depression, a ‘syndrome’, that is a cluster of symptoms that tend to occur together. But these symptoms are themselves very diverse. They include emotional changes (feelings of sadness often referred to as ‘dysphoria’, the opposite of euphoria); cognitive changes (low self-esteem, guilt, rumination, memory and concentration difficulties); behavioural changes (agitation or retardation, reduced engagement in social or recreational activities) and bodily changes (sleep, eating and sexual problems, aches and pains, loss of energy). Some of these have been seen as central to a diagnosis of depression and are shown in Table 1.1. Other symptoms are excluded because, although they very commonly occur in depression, they also occur when a person has other psychological problems. For example, ‘avoidance’ occurs in phobias, and ‘ruminations’ occur in obsessions, ‘passivity’ occurs in schizophrenia and ‘irritability’ occurs in mania. Most methods of diagnosis have a number of other categories so that the many people with a wider spread of less intense (though often very persistent) symptoms may be diagnosed. Table 1.2 shows these ...