Showing posts with label depression. Show all posts

Wednesday, July 12, 2017

Shades of depression in the cave

Shades of depression in the cave
Contents
Introduction    1
Cave Entry    2
Loss of meaning    2
Treatment    2
Social Element    3
Treatment    4
What then keeps us in the cave?    5
Learned helplessness    5
Punishment    5
Cognitive\Behavioural maintaining factors    5
Social element    5
Finally Time    6
Treatment    7
Summary    8
References    8

Introduction
In evolutionary terms, depressive symptoms can be seen a defensive reaction. Paul Gilbert sees depression as a return to the cave when overwhelmed to recuperate before returning back to the fray. This seems to agree with clients who talk of their depressive symptoms of not wanting to socialise for fear of being judged as boring or uninteresting, or not wanting to do things as they wouldn’t enjoy them or it would go wrong. They seem to be talking about protecting themselves from criticism, displeasure, emptiness and failure by withdrawal. In short if I don’t do and don’t engage it won’t go anymore wrong, I won’t be criticised and I won’t be hurt even more.
Therefore there are two aspects of depressive symptoms, what gets you into the cave and what keeps you there.
Cave Entry
Loss of meaning
Dorothy Rowe thought that the entry to the cave is due to a loss of meaning in your life, a gap between how your life is and how it should be and blaming yourself for this . The possible reasons for this gap seem varied:
1.    How my life is and how it should be, therefore I haven’t achieved
a.    Because how I’ve been treated (anger)
b.    Because I’m not good enough (depression)
2.    I have no knowledge of how my life should be its just not like this as its empty
a.    I did know but then I lost a life defining aspect (specific loss)
b.    Over the years what my life should be has made less and less sense (gradual loss)
3.    I can never have my life as it should be as I am in a social\cultural group that is mistreated
Treatment
It would seem then these three different aspects might call for different treatment approaches.
How my life is and how it should be, therefore I haven’t achieved
This seems to have two parts.
Firstly understanding the sense of how my life should be, opens up conditions of worth questions and also introjections. For conditions of worth the questions could be asked about the connection of achievement and love. For introjection then there would be the questions of where did this “how my life should be” come from and does it suit me now.
Secondly is the conclusion of why there is a gap, i.e. because I’m not good enough. This sounds the outcome of blame based criticism which asks the question of where being critical was learnt which may lead back to critical people in the client’s life. Then to how it is perpetuated which may show the internalisation of this original experience, to result in self-criticism.
Whilst there are different treatment approaches to self-criticism. It would seem understanding both the “traumatic” origins of self -criticism followed and a functional analysis of self or other criticism, to notice the effects, would be a good place to start. This could then be followed by a compassionate approach to self when things go wrong or encouragement is needed. If self-criticism pops up then a mindful\attention switching approach to something more valuable, in an ACT related way, would also support the compassionate approach.
I have no knowledge of how my life should be its just not like this as its empty
This is in two parts either due to a specific or cumulative loss of meaning.
Firstly with a specific loss you would be doing bereavement work with a view to integrating and accepting the loss both of the specific thing and the beliefs about how the world should be and then rebuild your life on the basis of this new foundation.
Secondly with the cumulative loss bereavement work would be harder as you have a cumulative bereavement but no obvious thing to grieve for. Here I guess there might be a move to look at all the times when there was a decline, what was the meaningful thing that was lost, to make sense and to grieve for that.
For both of these there is a need to reconstruct/reconnect with value, although possibly harder with the cumulative decline as there isn’t an obvious loss. There seems a few options here. Firstly to enable access to existing meaning through working with any of the blocks to that meaning, i.e. fear of failure, criticism etc., as people might know what might give them meaning but be blocked from engaging with it. Alternatively there could be a case of reconnecting to what has been important in the past but now lost. Finally you may need to create\discover meaning, which can be done in the same way that we did when we were kids, by trying, by following what others do and by doing what you are told to.
I can never have my life as it should be as I am in a social\cultural group that is mistreated
This seems a tough one in psychotherapy as it enters both the social and political realm, the abused child, and a person in an abused group. Safeguarding would be the first port of call, and risk management. Once the high level work has taken place, and the level of risk has reduced then the work here would be around firstly normalising and depersonalising, facilitating if there are any legal routes to pursue, and then finally noticing if there are treatment opportunities in terms of the reaction to abuse, even if you can’t stop that abuse, you can minimise it. Then in terms of cave entry, the how life should be gets modified to how the context of my life currently is.
Social Element
One aspect that is part of all the above ideas about cave entry is people and it merits talking about separately. There are a cast of people that help get people into caves and this can be due to how they act or how the client perceives them acting, or how they imagine they think.
To get cave entry then people need to be seen as not understanding you, or critical, or higher achievers than you, or more interesting, or treating you badly. You need to see yourself as not popular in the eyes of others, or others as not valuing you or your work. You can’t take the compassion of others or you wouldn’t get into the cave, you certainly don’t want to identify with others as similar to you, your depression needs to be because of your perceived dysfunctional characteristic. You need to suffer it alone although you can make it worse by thinking of how other people have it worse than you and yet they still manage.
There is a highly isolated aspect to depressive symptoms, there is a highly isolating aspect about them. In some ways inside the cave there is something of the social outcast, the hermit, again this is a self-outcast, apart from the person who is abused by group or context.
So to understand entry to the cave, what were the roles and changing roles of the others significant to this entry, they may be known people, film stars or anonymous friends on Facebook. They define the life that should be, that persecute me through what they believe, who taught me self-criticism by criticising me, who bullied me to plant the seeds of I’m useless.
Treatment
As we get to meet this cast, then we get the chance to get to know them better, as this happens so we can open up different thoughts:
Is their life as good as it seems and would it suit you?
What do you make of people that bullied and criticised you, does their behaviour say anything about them?
There is a good chance that the person with depressed symptoms has some of this casts voices and attitudes as their thoughts\beliefs and values. So as we get to know them better, we effectively get to know some of the cognitive mechanisms that takes the person into the cave.
In some ways the “cognitive restructuring” is more about getting to know about the specific people who made for the cave entry and then also other people. In understanding the cast then we enrichen their behaviour, if their behaviour was critical then there were reasons for this, and not all of them were about you. If their life seemed to be envied, then as we understand more about it, we hear more about their suffering.

What then keeps us in the cave?
I will mention three main ideas here, learned helplessness, punishment and cognitive/behavioural factors.
Learned helplessness
Seligman tells us of learned helplessness, i.e. pessimism towards our self-efficacy, through interpretation of misfortune in terms of the continuums of personalisation, pervasiveness and permanence . So if you interpret misfortune because it was your fault, you always mess up and always will, then this leads to learned helplessness. So you stay in the cave as you have no belief in your ability to either define or live the life you want so you seek damage limitation.
This in some ways helps us to understand the difference between the reactions of unhappiness and depressive symptoms to unpleasant events. The former has hope, and will accept comfort and give themselves it where the latter does not.
Punishment
Rowe would also add that if you have learnt to believe yourself as bad, either as a result of taking the blame as a child, or the outcome of continued criticism\self-criticism, then “You review the stupidities and failures of your life and punish yourself for crimes known and unknown” (Rowe, 2003, p. 6). Again you stay in the cave as both prisoner and gaoler.
Cognitive\Behavioural maintaining factors
The following seem to perpetuate low mood, and keep you in the cave:
1.    Low value activity: creates low mood and continues depressive thoughts about self, world and others.
2.    Self-criticism: telling yourself how you are no good/incapable.
3.    Comparisons telling yourself you’re no good in comparison with others
4.    Rumination: The replaying of all the bad things in your life, both lowers mood and reinforces depressive thoughts about self, world and other
5.    Self-care: reducing self-care leaves you to experiencing yourself as of low value in society and having low abilities.
6.    The inability to accept compassion (this would confirm low status) or give it to one self (kindness would condone your position)
7.    An inability to make meaning out of our depressive symptoms: the future is hopeless as you can’t imagine the ending of this story and the next chapter.

Social element
Again with the elements above there contains a social element.

There is a cast of people that keep people in the cave, be they real or imaginary. These are the people who would criticise, whose lives are better, who don’t understand you and say the right thing.
So in the work to forge an escape there is an aspect of re-engaging with people, to reduce the sense of isolation and that its only you that suffers, to get the validation of your worth as a person because people want to take the time with you, to challenge the ideas of both the levels of unpleasantness that people will be to you and how awful it would be if they are. Likewise as much as you reconnect with people, repopulate your life so there is a virtuous circle of feeling better about yourself due to the validation, a reduction in isolation, which is a form of torture used throughout history, and a opening to both the meaningful activities you can do with or for others. Again as this happens we get to either challenge the beliefs we have about other people:

The interesting other who I must stay away from as I will bore them.
The critical other who will laugh at me as I struggle to do things I used to excel at.
The other who is better than me, whose life is what my life should be.
No-one understands my suffering
They don’t suffer like I do

There is also a relationship to yourself that keeps you in the cave
I must criticise myself to motivate myself
I must ruminate to learn
I shouldn’t care for myself
I must not be compassionate to myself
The effect of this is there is hostility outside the cave from people, and inside the cave there elf-hostility, an “it’s good for me hostility”, almost boarding school hostility if I can call it that.

Finally Time
One last thing to mention before I say goodbye is to mention time, which is rarely mentioned. In the cave time is heavy, slow and painful. This is sometimes worth noticing both as a depressive symptom and also something that can be engaged with, as non-cave activities, or shall we say escape route have a different cadence, a different way times feel that can help guide the cave dweller back home.

Treatment
In some way the bed rock of coming out of the cave is self-care, self-compassion and making meaning. I guess without some looking after yourself and care towards yourself everything else becomes much harder. So in some ways this might be the place to start.
The entwined nature of life however would also point out that self-care is reduced because of low self-valuation which is maintained by rumination, self-criticism, comparisons and low value activity. So I guess here is to find an “in”. Somewhere you can make a difference, and in some way as you reduce the low value creating activity or inactivity, then to increase self-care and compassion would seem to be the way to go as this could create more momentum for tackling the next cave staying aspect.
Meaning seems also key: to make sense, to make meaningful how you got into the cave and therefore the meaning of being in and getting out of the cave would also seem important. It places cave dwelling as part of a narrative that shows how the main character, gets his second chance, overcomes his adversities, learns and builds on his prior mistakes to a phoenix return. As soon as you can make sense of cave dwelling and escaping, it offers you a method to get out, and you can orient yourself with this narrative.
So after we provide some foundations then we need to tackle the different shades of cave dwelling:
If learned helplessness seems powerful a good anti dote to this would be shaped behavioural activation as you want to enhance self-efficacy.
If there are core beliefs around about being bad\useless etc. compassion work would seem a soothing balm.
If self-criticism is high then to understand its purpose, generally to do with learning and motivation and then to see its effects and seemingly then the encouraging aspect of compassion seems helpful.
If rumination is high then to understand its purpose and effects seems critical, again to notice the secondary benefits that the rumination might be an attempt to hold onto a view of the world that I had good parents or it’s a just world etc. Attention switching\mindfulness to more valued activity seems helpful in this space.
If comparisons are high then you can work with them in the same way as self-criticism as they are part of this in that you compare with yourself to result in a critical attitude to yourself.
The social element of staying in the cave seems about using some of the techniques to cave entry back with the client. So as often peoples self-relation is a lot harsher than their other relations, you can use comparison to ask would you say that to a friend. In the face of self-criticism or rumination learnt from a significant other you can invoke a compassionate other be it as an individual or composite of individuals and ask how they would react to you. You can also bring in the imaginary person, if you had a child and something went wrong, would you encourage them to criticise themselves and ruminate. So in some ways this is a cognitive restructuring but the method is through relations. It uses the same mechanisms, comparisons, imagination and memory but just with different people, people that you love or loved you. In some ways it seems less of a cognitive curiosity rather a meeting old friend and maybe even new ones.

Summary
Entry to the cave happens like this:
1.    Feel distress in life
2.    Consider the reason for this that I’m not living or don’t know the good life
3.    Consider others better than me\punitive and uncaring
4.    Go to the cave to minimise damage, no mistakes, nothing goes wrong, no criticism, no failure as I’m not trying and that’s the reason I’m depressed.
And you stay in the case like this
1.    Through learned helplessness consider I can’t find out how to get\live the good life
2.    Use the depressive cognitive\behavioural maintaining factors mentioned above

Whilst it seems significant to address the cave entry ticket to both ensure early release and prevent relapse, the maintaining factors whilst related to the entry ticket are significant and without treatment of these escape is unlikely. Of course the division isn’t as clean as this and the maintainers will also be seen in the cave entry and vice versa, but logical clarity here seems helpful.

Of course I guess one obvious answer to all of this not mentioned above, it to make a really swish cave, all bear skin, plasma, wine and grapes and wait for everyone else to come to yours, but then that is another story….bye now.

References
Gilbert, Paul. The Compassionate Mind (Compassion Focused Therapy) (p. 40). Little, Brown Book Group. Kindle Edition.
Rowe, Dorothy. Depression: The Way Out of Your Prison (pp. 18-19). Taylor and Francis. Kindle Edition
Seligman, Martin E.P.. Learned Optimism: How to Change Your Mind and Your Life (p. 58). Knopf Doubleday Publishing Group. Kindle Edition

Monday, April 22, 2013

Overcoming Depression One step at a time: Addis & Martell

Overcoming Depression One step at a time

Part 1 Understanding Depression

Introduction

Read a chapter a week and do the exercises, this will take 8 weeks.

25% of people will experience depression in their lifetime and depression has trebled since WW2.

Maybe this is because of a depressogenic society we rely more on technology less on each other and have become alienated and isolated, button pushers. At work we are human resources, to be played like a game of chess, and we live in nuclear families divorced from our extended families.

End jobs, relationships, losing loved ones, moving house, all put you at risk of depression.

Chapter 1 How depression works

Depression rarely has one cause, its complex, and it isn’t necessary to determine the cause to end depression. With chemical imbalances it isn’t clear if depression causes the chemical imbalance, vice versa or a combination. The quickest way to remove an influence from the past is change how you live in the present. Medication helps some people but not everyone.

Depression isn’t a problem in you, but rather a problem between you and life.

Depression is 5 of

1. Sadness or depressed mood

2. Loss of interest in things

3. Significant weight change

4. Sleep problems

5. Feeling very restless or feeling very slowed down

6. Being tired all the time

7. Having thoughts\feelings of worthlessness or guilt

8. Difficulty concentrating

9. Having repeated thoughts of death or dying

Depression is a complex of

1. Emotions=Sadness, feeling down

2. Cognitions=thinking I’m worthless, there’s something wrong with me, thinking about death

3. Behaviours=inactivity, loss of interest in doing things

4. Physiology, sleep problems, eating problems, low energy, depletion of serotonin

5. Situations: loss of job, partner and loved one

Whilst you may feel depressed through a life event\vulnerabilities, you stay depressed as you stop doing things that make you feel good.

Avoidance is used to stop people feeling worse. However this is a short term gain and long term pain. You may see behavioural avoidance, e.g. worrying about money is a way of avoiding feelings of loss or sadness.

Clients respond to BA saying sound like pull my socks up and I’ve heard it before. Changing behaviour isn’t easy, behaviour becomes habit and it’s done automatically, changing behaviour means taking some risk, maybe experiencing different things, maybe doing something with an unknown outcome and it also involves quite a few choices to find the right behaviour for the right time. So it’s not easy!

Commonly people think that emotions cause behaviours, why are you staying in, because I’m depressed. However behaviour, doing something you enjoy will cause happiness, doing something you don’t unhappiness.

Inside out

Taking medication, fixing something inside of you is an inside out approach. If you take an outside in you work on the principle that behaviour can cause emotion, if you take the inside out you work on the principle that emotion causes behaviour, both are true, but if you’re depressed you probably need to take the outside in approach.

Chapter 2 Learn your patterns and start to change them

What are your behavioural patterns when depressed, worrying, complaining, passivity?

Behavioural principles

1. Most behaviour is automatic and occurs out of consciousness

2. Most of what you do is habit

3. The first step to change behaviour is to recognise it and its consequences.

So do an activity monitoring chart on an hour by hour basis (no emotions), sell this on the fact that most behaviour is automatic and we aren’t aware of it, and often don’t remember it. Many activities you enjoy when you are not depressed may not be ones that you enjoy when you are depressed. It’s possible when you start doing something you used to enjoy that you don’t immediately start enjoying it, however if you stick with it will you refind what you used to enjoy in it? Also notice about how different contexts and different ways of doing the same thing have different effects, eating your favourite food in a rush, vs. thinking I’ll treat myself, looking forward to it, then eating it slowly. When you find the variations in depression, that can give you indicators of what to increase. If you find a person has singular emotions, try getting activities done that create other ones, go to a comedy club, to a sad film. Also find out what it is about the situations that make a decrease in depression. Have you stopped ruminating?

Step 1. Activity Monitoring chart

Step 2. Activity and Mood monitoring chart (add in as much context as possible)

Step 3: look at chart and look to see what you can understand

1. Variations in mood

2. Difficult\easier times during day

3. Difficult\easier situations and activities

4. Depression loops (When you attempt to cope with depression but it makes it worse)

Step 4: Making strategic changes

1. Identify situations\behaviours that depress you

2. Establish current behaviours (presumably not functional)

3. Establish behaviours that would reduce depression (more functional)

4. Select alternative behaviours and schedule them into your week

5. Adopt an experimental attitude, try the alternative behaviour and see the results

6. Evaluate results of experiment

a. If it didn’t work what did you learn

b. If it did work what did you learn

7. Try new experiments

Depression can sometimes act as a devil on your shoulder telling you how it won’t work, how you’re a failure etc. When you’re really depressed it can be worth just letting him have his say (arguing with him can just keeps him saying what he’s saying) and try the new behaviour anyway and see what happens.

When you try new behaviour, become as fully involved in it as possible. Focus on what you’re doing rather than things that have happened in the past. So when you’re walking, then walk, notice what’s going on around you, if you are ruminating while you are walking, you are ruminating and just happen to be walking at the same time. Also avoid evaluating the experiment whilst it’s going on, immerse yourself in the activity and then check out the experiment after. Also try the experiment more than once, good scientist always repeat their experiments to be sure of their findings.

Part 2 Ending Depression

Chapter 3 Getting out of TRAPs and back on TRAC

The central aspect of avoidance, is what are the things you need to get the life you want. Is what you are doing helping to get there, or is it avoiding some difficulties you find in getting there.

There are two types of avoidance

Avoidance and escape behaviour

Escape behaviour gets you out of an unpleasant situation, avoidance stops you getting into one. The difficulty with both of these is whilst they may in the short term make you feel better as you don’t have the unpleasant situation, if this is something you need to do, to make your life more rewarding then the long term consequence is a less rewarding life. Whilst avoidance is natural and everyone does it, it can make getting out of depression difficult. Avoidance can come out of our fight\flight response that was useful in the preindustrial world, but not as useful in the post industrial world.

Avoidance can be very subtle, so instead of working, checking FB. Sometimes fatigue can be a way of avoiding difficult feelings. Sometimes staying in bed is a way to avoid all the bad things that could happen to them if they got up. Sometimes the things that are avoided are the thoughts and feelings you will have if you do something. So the avoidance may be thoughts\emotions\ or thinking behaviours.

Avoidance can be adaptive, e.g. avoiding dark streets, but can be maladaptive if you don’t learn to solve your problems as it keeps the problems alive, and decreases your confidence in your problem solving ability. Avoiding things can also compound them, e.g. pink rabbit experiment. The function of a behaviour is determined by its consequences (NB). To understand avoidance look to understand the circumstance, does it feel difficult and what are the consequences, have you solved a problem, made things better for yourself in the long run or just in the short run, are there any unwanted consequences.

TRAP

Trigger, this quite often is an event, or a chain of events.

Types of Triggers

1. Historical

2. Current Internal\External

3. Interpersonal

Triggers can be historical, i.e. someone shouting associated with big danger, or an anniversary, or a song playing on the radio. Then there are current triggers, so facing a difficult situation, could trigger anxiety, or some loss could trigger sadness. There can be external triggers, things that happen to you, or internal triggers, e.g. noticing your heart beating quickly, or a thought, or an image, or worrying.

Response, usually emotional, could be thoughts, so you get triggered to feel sad, or maybe you start thinking how bad things are.

Avoidance Pattern.

This could be drinking or escape behaviour or safety behaviour

Learning about avoidance

Step 1: list the things you avoid that are adaptive, and maladaptive

Step 2: Learn your TRAP

Step 3: generate alternatives that are not knee jerk responses

Step 4: Learn your TRAC

Facts about responses to triggers

1. Responses to triggers are often emotional

2. Attempts to get rid of unpleasant feelings are often unsuccessful, and take your eye off what you were trying to do

3. Society often encourages you to get rid of bad feelings

4. The alternative is to feel what you feel and carry on acting according to the goal that you have

Reactions

Whether an avoidance strategy is helpful depends on the short and long term consequences.

Avoidance is a key process in maintaining anxiety and depression. Fear is often a response that triggers avoidance, I just can’t face the day because I know I’m going to feel miserable, i.e. I’m frightened of the day. Sadness likewise triggers avoidance, where I’m sad, due to loss, and I don’t want to engage with people. Anger too functions in the same way, it might have been a prohibited emotion as a child so when felt it needs to be avoided.

Avoidance patterns

Procrastination as avoidance: when a task is difficult you avoid doing it, until it becomes so pressing you have to. Some of the symptoms of depression can function as avoidance, e.g. tiredness, negative thinking (you may use negative thinking instead of responding assertively to others), complaining, moaning, Rumination avoidance emotional\imaginal pain. Numbing, spacing out can help avoid feelings of sadness.

Recognizing TRAPs

Man in a desert, drinks vodka, refreshed for a moment, then dehydrated, then disorientated. Avoidance works the same way, short term relief, long term pain.

Are you tired and need sleep as you have worn your body\brain out, or are you tired and want to sleep to avoid painful feelings. There is a difference between sleepy and fatigues, where the former is used energy up need to replenish, the latter is ground down, down want to be awake anymore, but it’s not tired. To tell the difference if you wake feeling refreshed, it was worthwhile, if you wake feeling tired then it may well have been fatigue.

How to get back on TRAC

Trigger

Response

Alternative coping response

If you expect to do something first time and it be pleasurable\doable, if it’s not then you’re likely not to try it again, you’re likely to avoid it.

Self-soothing as alternative coping

Self-soothing can be useful, as can avoidance, if you get your resources back and approach what you need to. Self-soothing and avoidance aren’t useful, where you reduce the unpleasant feeling, and don’t approach the problem. There is also a big difference between soothing and anesthetising. So does self-soothing make you able to tolerate pain such that you can do what you need to, or does it remove the pain and mean you don’t do what you need to?

Chapter 4 Taking ACTION: First Steps toward Change

· Avoid criticising, shaming or blaming yourself into change, you will feel coerced and resentful.

· Just do it doesn’t work or you would have done it

The best way to change is to firstly understand what you do and how it makes you feel. In here you might see some things that you can increase\decrease doing to improve mood. Likewise you can take things you are doing and look for similar but more functional alternatives. This way change is gentle and organic and related to what you are doing already.

Action=

Assess your mood and behaviour

Choose alternative behaviours

Try out alternatives

Integrate these changes into your life

Observe the results

Now evaluate

Common problems:

· Inactivity

· Lack of assertiveness

· Worrying\self-criticism

· Repeated conflicts

· Too much work not enough play

Feeling hopeless may well be a symptom of depression rather than a good predictor of the future.

Choosing Alternative behaviours

· The goal is to take a choice rather act automatically, so even if you only make something a little better that’s a good move!

· Make choices that are achievable, don’t set yourself up to fail

Difficult with choosing?

· Choices are not well defined, e.g. be optimistic

· Fear of failing: if you have huge anxiety in front of a new behaviour maybe you need to try a smaller target.

· Try alternatives at least three times before making a decision as to how useful or otherwise they are

· Making a public or written commitment to change often helps make that change

· Trying new behaviour can make you feel awkward

· Integrate change into your life, create a routine that supports the new behaviour, a certain time that things happen, certain things that happen before and after.

· People have shown that disruptions to routine can put you at risk of mood disorders

· You only know how to do a new behaviour after practising it a while, imagine the first time you rode a bicycle.

Difficulty integrating change

· Too many changes, start slowly and integrate things, then add another, so each one is bedded in

· Trouble following through, i.e. great idea, but not implemented. Then what are the obstacles, how can they be addressed.

Observe the results

· Before doing the new behaviour, note your mood before doing it, how you feel during the experiment and your mood directly after it is over, and how you feel during the rest of the day

Choices

· We have a lot more choices than we are aware of, look to see what yours are, minute, by minute, hour by hour

Chapter 5 Stop worrying about your inner child and develop your outer adult

The idea here is that understanding why you are depressed, through what has happened to you, what your character is, can sometimes be unhelpful to overcoming depression. Looking for causes doesn’t lead to solutions. This approach can lead to worrying and rumination. A clearer approach is to find out what is keeping you depressed.

Reasons why we think

· To fix a problem

· To hold onto negative thoughts about past events as otherwise it would let people off the hook

· As a way to avoid doing things

· As a way to avoid what’s happening in the present

So what you need to work out is what is the function, what is the purpose of my current thinking.

Ways to describe ruminating

1. Over thinking

2. Brooding

3. Worrying

4. Obsessing

5. Stewing about a problem

How to deal with ruminating

Step 1: Establish what your rumination topics are

Step 2: Notice the impact of ruminating on your mood and how you think

Step 3: CBA on rumination

Step 4: Establish if rumination helps you solve problems (your focus changes to yourself not the problem)

Step 5: Do an ABC on ruminating

Step 6: See if there are things you are avoiding doing by ruminating

When you ruminate, you cut yourself off from the world. This prevents you getting pleasure from the world, getting opportunities and information. All of these factors can lead to depression. Rumination can also highlight things, make them seem as if they are present, so bad things you have done or have happened to you, will seem like they are continuing in the present.

Distinction between problem solving and ruminating. The former you only think about the problem, long enough to solve it, or to evaluate choice, or to work out how to implement. The latter is abstract and evaluative.

Distinction between experiencing and ruminating. The former experiences the emotion, the latter thinks about it and its consequences. If you actively feel the emotion it tends to pass reasonably quickly, if you brood about it then it can last a long time.

Treatment for rumination

1. Recognise when it happens (You’re ruminating when: you think without solving problems, you think over and over negative thoughts etc., the process of thinking makes you feel more depressed)

a. 2 minute rule

i. Continue thinking for 2 minutes

ii. Ask yourself:

1. Have I made progress to solving a problem

2. Do I understand more about the problem

3. Do I feel less self-critical, less depressed than I did before

2. RCA=Rumination cue to Action

a. Notice your ruminating

b. Generate a list of alternative activities

3. Attending to experience: when you fully immerse yourself in a task you spend less time thinking about yourself

a. Listen to sounds

b. Smell the smells

c. Feel the feeling

d. Look at the sights

Part 3 Activation as an approach to your daily life

Chapter 6 Make changes one step at a time

Depression you become shut down, have low energy, no motivation and don’t take pleasure in the things that you used to do. A person with a broken jaw used to enjoy steak, whilst it’s healing how can they enjoy steak. The thoughts around having no motivation are what’s the point, its hopeless etc. Depression has been evolutionarily adaptive as it has helped us shutdown whilst we heal, or it can be adaptive as it means that the current course of action isn’t adaptive, so for instance challenging a boss where you won’t win and if he leaves you it would create greater harm than good.

Some theorists say depression is a result of interpersonal relationships (Klerman 1984), so loss of personal relationships leads to depression. When depressed it’s difficult to improve relationships or to create them. So take the outside in approach, write a plan for how to get the relationships that you want.

With any goal it has component parts.

Making and maintaining friends

Write down a list of casual acquaintances and mark those who you’d like to develop into friends

Choose a couple of people to call or write to

Have a cup of coffee with one person

Invite family or friends over for a meal

When you choose what you want to do, break it down into small steps

Having a difficult conversation

Avoiding conflict will keep it going, getting angry and attacking someone is unlikely to help either. For a difficult conversation best to make a plan so you don’t act from emotions which may be quite high. Only set goals that are in your control, so if your partner hurt your feelings by being late, the most you can do is tell them how you felt

Types of human interaction

1. Be physically around people

2. Emails etc.

3. Brief interactions in public, stores etc.

4. Symbolic greeting, nodding head

5. Offering a token, I’m going for coffee would you like one

6. Ask for a favour

7. Share what you have in common

8. Make small talk: social axel grease, eases you in to something more significant

If you haven’t got much to say, as you haven’t done much because you’ve been depressed, ask about what the other has been up to, take interest in them.

If little tasks feel overwhelming and you can’t do them, then this can leave you with a feeling of failure. Break the tasks down into baby steps and do one. If that’s too much, break them down even more. So get a list of tasks to do, and when you do one, just concentrate on the one in hand.

If you find tasks difficult, rate them on your own current suds scale, not what you should be like when you’re not depressed, or how other people think you are, how it is for you. This then can get you to do your component tasks easiest one first.

Chapter 7 Free yourself from mood dependence

If you wait until you don’t feel depressed, so you have motivation and energy to do things, then you could wait quite a long time. So you can either do small things, or do things you normally do, but do them in a different way, then you can get the enjoyment from the small thing or the normal thing and this will start to change your mood.

In the west we think mood determines, even controls behaviour, but there are other things, our goals, our thoughts and rules can override emotions. Think of a behaviour you can’t do, how much would you have to be offered to do that. So you can override your emotions if it is important enough to you. Mood and emotion influence behaviour but don’t control it. Also sometimes emotions can be wrong, you feel anxious but actually there’s nothing to be scared of.

When you are depressed or anxious it can be more helpful to operate according to a plan. You might feel like you can’t do anything but test it out see what you can do, and remember the 1000000 incentive, that you could do it if the reward was big enough. Physical problems can stop you doing things, but depression does make your pain feel worse, so again test out and see what you are capable of. If you are ill and you say you couldn’t cope with x how much is it your cold telling you, how much is it depression.

It might feel awkward to act according to your goals rather than your mood. Like you are being fake. However you are being true to your goals, your desires it’s just it might feel a bit awkward with your mood. But then that will change. Does your mood define you, or do your goals, or a bit of both? Just imagine what it would feel like if you had a broken arm, then the cast came off, how would it feel say eating or driving, how would it feel if you continued doing it.

Sometimes setting goals can be difficult as you think what’s the point I will never achieve them, but this is just mood dependent thinking. A good goal is one that you have influence over and one that you value.

As you make long term goals, mark them down as realistic and desirable. This will help you prioritise your goals. Long term goals are achieved by a collection of short term goals.

If you find it hard to achieve your goals, finding that you are being forced to achieve them, but you don’t feel like it, remind yourself that it is you that values them, that you will be missing out if you don’t achieve them.

Studies show that how we act affects how we feel, the test was to try to keep a pencil between your upper lip and your nose, people which forces the lower part of the face to smile. People who did this reported a better mood than people who did not.

If you want to feel different, act different. So how would you be acting if you had motivation, how would you be acting if you weren’t depressed? Act like that and let the mood follow your behaviour.

Chapter 8 Build the life you want

Chances of depression returning increase after every episode of MDD. Each change you make, makes a new history for the future. The past can seem to be causing the present as the feelings associated with past events are almost as strong at the original feelings. We react differently to our past experiences, some we have been influenced by and vow never to repeat, e.g. some of the ways our parents acted. Words, thoughts, smells, sounds, physical feelings can all be evocative of emotions, through their association with past events.

When you recognise yourself doing things that imitate people in your life, that you don’t like, try altering them, doing the opposite. Again for behaviours that you respect from people in your life, try imitating them, find out exactly what they did, and do it for yourself. It’s much easier to do something positive, rather than stop something negative. Replace things don’t stop them, nature abhors a vacuum.

Problem solving is a great antidote to depression.

What is the problem, is a useful question as it promotes you finding a solution, why I have this problem less so as the cause of the problem isn’t necessarily useful to finding a solution, well, especially with mental health difficulties. Making problems more concrete helps us solve them.

Problem solving:

1. Define the problem concretely what is the problem

2. Brain storm solutions

3. Give pros and cons for each solution, short and long term consequences, resources required etc.

4. Choose best solution, or create an amalgamation of the solutions to get the best solution

5. Implement solution

6. Test outcomes

Some problems have no solutions, we will die and our friends with. With problems such as these then acceptance is needed. Again some problems you haven’t got control over so you may need to accept. Life has suffering, happiness and joy. Only accepting the joy in life is not accepting life.

The kindness of others, a support network, helps you with the adversities of life. Self-soothing is useful in the absence of companionship, the hot bath, the lovingly cooked meal. Self-soothing is different to self-anaesthesia. Self-soothing is engaging in life and treating yourself well, as a valued person.

Chapter 9 Tying it all together

Forms

Activity Monitoring

Time	Yesterday	Today
Midnight
01:00
02:00
03:00
04:00
05:00
06:00
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00

Activity and Mood Monitoring

In each box write down the activities that you engaged in during the hour and how you felt. Rate your feeling on a scale of 1 to 10 with 1 being the least intensity of feeling and 10 being the most.

Time	Day and Date:
Midnight
Mood
01:00
Mood
02:00
Mood
03:00
Mood
04:00
Mood
05:00
Mood
06:00
Mood
07:00
Mood
08:00
Mood
09:00
Mood
10:00
Mood
11:00
Mood
12:00
Mood
13:00
Mood
14:00
Mood
15:00
Mood
16:00
Mood
17:00
Mood
18:00
Mood
19:00
Mood
20:00
Mood
21:00
Mood
22:00
Mood
23:00
Mood

Finding the behaviours that make you feel bad, and an alternative

Look back over the activity and mood monitoring charts that you completed over the last week. Choose one or two situations and corresponding behaviours that seemed to make your mood worse. If you mood was steadily depressed with little variation, pick a situation and behaviour that clearly did nothing to improve your mood and could be changed. Try to find behaviours that occur somewhat regularly during your week. You’re looking for regular patterns that can be changed. In the spaces below, fill in the days of the week and time of day, the situations in which the behaviours occur, and your current behaviours in the situations. For now, leave blank the space for alternative behaviours. As with the activity and mood monitoring chart, try to be as detailed as possible.

Day(s) of week and time of day:_______________________________________________________

Situation:__________________________________________________________________________

Current behaviour:__________________________________________________________________

Alternative behaviour_______________________________________________________________

__________________________________________________________________________________

Day(s) of week and time of day:_______________________________________________________

Situation:__________________________________________________________________________

Current behaviour:__________________________________________________________________

Alternative behaviour_______________________________________________________________

__________________________________________________________________________________

TRAP Worksheet

Instruction: Fill in the blanks for four different TRAPS that you find yourself in

TRAP 1

Circumstance:______________________________________________________________________

Trigger:____________________________________________________________________________

Response:__________________________________________________________________________

Avoidance Pattern:__________________________________________________________________

Consequences:______________________________________________________________________

TRAP 2

Circumstance:______________________________________________________________________

Trigger:____________________________________________________________________________

Response:__________________________________________________________________________

Avoidance Pattern:__________________________________________________________________

Consequences:______________________________________________________________________

TRAP 3

Circumstance:______________________________________________________________________

Trigger:____________________________________________________________________________

Response:__________________________________________________________________________

Avoidance Pattern:__________________________________________________________________

Consequences:______________________________________________________________________

TRAP 4

Circumstance:______________________________________________________________________

Trigger:____________________________________________________________________________

Response:__________________________________________________________________________

Avoidance Pattern:__________________________________________________________________

Consequences:______________________________________________________________________

TRAC Worksheet

Instruction: Fill in the blanks for TRACS that you could use

TRAC 1

Circumstance:______________________________________________________________________

Trigger:____________________________________________________________________________

Response:__________________________________________________________________________

Possible alternative Coping behaviours:__________________________________________________

__________________________________________________________________________________

Choose One alternative to Try:_________________________________________________________

__________________________________________________________________________________

Commit to a time to try it:_____________________________________________________________

Consequences:______________________________________________________________________

TRAC 2