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Clinical Depression is so widespread that it has been called 'the common cold of psychiatry’. One in every five woman in New Zealand will develop a depressive disorder at some stage during their lifetime – a lifetime prevalence of 19.4% for females, compared with 10% for males (Wells et al, 1989). Between 20%-25% of people with a major depressive disorder are likely to contemplate or attempt suicide. (The Core Debater, Feb 1995)
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), Major Depressive Episode is characterised as follows. There is either depressed mood or a loss of interest or pleasure in daily activities which represents a change from the person’s normal mood; social, occupational, educational or other important functioning is negatively impaired; and at least four of the following are present: significant weight loss or gain, decrease or increase in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, indecisiveness, recurrent thoughts of death, and suicidal ideation.
Note that clinical depression has been sub-classified in a number of ways, including bipolar, unipolar, endogenous and reactive. The term 'depression’ used in this article refers to a non-bipolar, non-psychotic depressive episode.
The cognitive-behavioural theory of depression
Cognitive-behavioural theory comes from a variety of sources, the two main streams being 'Rational Emotive Behaviour Therapy’ (REBT) developed by Albert Ellis; and Aaron Beck’s 'Cognitive Therapy’ (CT).
From a cognitive-behavioural point of view, the essential component of depression is a negative cognitive set: a tendency to view the self, future and the world in a dysfunctional, negative manner, which Beck (1967) has termed the 'negative triad’. The major symptoms of a depressive disorder, affective, behavioural, somatic and motivational, are viewed as a direct consequence of the negative thinking pattern.
Experience leads people to form assumptions about themselves and the world which are then used to perceive, govern and evaluate behaviour. The need to predict and make sense of one’s experience is vital for normal functioning, but some assumptions are rigid, extreme, resistant to change and thus counter productive. It is important to note that these assumptions alone do not account for the development of clinical depression. Problems develop when critical incidents (activating events) occur which mesh with aspects of an individual’s personal system of beliefs. For example, a belief that 'to be loved is essential to happiness’ could lead to depression if triggered by rejection. Once activated, dysfunctional assumptions produce an upsurge of 'negative automatic thoughts’ leading to depressive symptoms. eg. withdrawal, loss of interest, anxiety, guilt etc. As depression develops, negative automatic thoughts become increasingly frequent and intense and more rational thoughts are crowded out.
Note that according to the cognitive model, negative thinking does not cause depression – it is part of it. Also, there is no qualitative difference between the thinking processes of most depressed people and the thinking processes of euthymic people; rather depression exaggerates and intensifies processes present in all of us.
To sum up, depression needs to be seen as a final common pathway for a range of biological, developmental, social and psychological predisposing and precipitating variables (Hawton et al, 1989). This model can be visualised with the following diagram (adapted from Froggatt, 1998):
The turmoil of depression is experienced by both sexes. Irrational beliefs are not the sole province of one gender; why, then, is it that depressed women greatly outnumber men?
Humans move easily from being critical of their behaviour to condemning themselves, but the particular way in which we creatively 'do ourselves in’ may be partly related to the culture in which we live. The societal environment of females is not equivalent to the societal environment of males. Blechman, 1984, states that 'The world tends to treat a woman differently from a man, even when the two have similar capabilities…’
In research studies where actual competence levels between men and women did not differ, women were nonetheless more likely to assume that they did poorly, to condemn themselves as incompetent and to feel more dysphoric as a result (Walen 1998). So, while the quality of self-rating beliefs is not unique to women, their frequency of occurrence and intransigence to removal may be greater in women by virtue of their social experiences. 'Women are socialised to attribute success to luck and failure to lack of ability. In contrast men attribute success to ability and failure to bad luck’ (Beckham, 1995).
Jack (1984), in her study on women and depression (as cited in Steen 1996), reached the implicit conclusion that to be female is, because of personality formation, to be in greater danger of becoming depressed.
Nearly all women with depression would experience passive suicidal ideation at some stage during their illness. 80% of all suicides can be related to depression. Women are three to four times more likely to make suicide attempts than men (though men are more likely than women to complete suicide). Major depression is the psychiatric diagnosis most commonly associated with suicide. According to Shuchter (1996) 'The best protection against suicide is the effective treatment of the depression’. Suicide contemplation results from certain dysfunctional beliefs and attitudes:
Cognitive behaviour therapy
Cognitive behaviour therapy is an active, directive, structured, psychoeducational approach based on the cognitive-behavioural theory of causation: 'Men are disturbed not by things but by the views they take of them’ (Epictetus, 1st Century A.D.). There are three main assumptions underlying CBT: (1) emotions and behaviours are determined by thinking; (2) emotional disorders result from negative and unrealistic thinking; and (3) by altering this negative and unrealistic thinking, emotional disturbances can be reduced. The process of CBT involves teaching the client to:
(Trower and Casey, 1988)
The immediate target of CBT for depression is symptom-relief. The long term goal is to solve life-problems and prevent or minimise future episodes of depression.
CBT as feminist therapy
The major goal of most feminist therapists is to aid the client in making the transition from (1) the childlike, helpless, submissive person she was socialised to be; to (2) an autonomous person with personal strength, independence and trust in herself and other women. Janet Wolfe (1975) believes there is no therapy which better suits the requirements of a truly feminist approach than cognitive-behaviour therapy – because CBT encourages autonomy, self development, and positive feelings about oneself; helps to re-channel rage, minimises the power differential between therapist and client, and provides in the therapist a healthy role model. Wolfe and others have described some typical irrational, self-defeating beliefs that are most relevant to women:
Janet Wolfe (1995) believes that a large number of the 'shoulds’ that underlie a womans irrational beliefs are fed from the deep well of sex-role socialisation shoulds, e.g. 'I must be married and have kids in order to be normal and fulfilled’.
CBT is anti-absolutist. There is no one right or normal way a person should be. CBT helps women deal with the shoulds, self-rating and love-slobbism inherent in female sex–role messages and provides a concrete method for disputing them.
Treatment: getting started
Engaging the client
My first step in working with Jane was to engage with her and her family and build a therapeutic relationship. This involved (1) showing empathy, warmth and respect; (2) checking for secondary problems about coming for help, especially shame and self-downing; and (3) reassuring Jane and her family that she would recover soon (as Steen 1996 puts it: 'Being told they will recover and that they are not crazy was seen as very helpful and something that needed to be repeated over and over during their blackest moments. Many women talked about feeling crazy. To know they were not crazy and would eventually feel better gave them the hope they needed to struggle through their pain and become healed’).
We began the assessment phase with Jane’s perception of what was wrong with her and her thoughts about being diagnosed with clinical depression. Then we examined the following aspects:
Introducing the treatment rationale
Next, I introduced Jane to the concept of CBT as a treatment method. She appeared receptive to the idea of rational and irrational thoughts and recognised their relevance to her own experiences. We talked about the equal, collaborative relationship that this form of therapy requires. She reiterated that she likes to feel in control and agreed to work with me rather than expect me to 'cure’ her.
We talked about the length and frequency of the sessions, agreeing initially to meet for one hour twice-weekly, reducing to weekly sessions once her distress and depressive symptoms began to lessen.
I also talked with Jane about the importance of setting the agenda for each session, and we agreed that as part of our agenda each session we would:
Managing and treating suicidal ideation
At every contact I had with Jane I would take particular care to prioritise dealing with her feelings of hopelessness, suicidal ideation and negative expectations of treatment.
During our assessment session Jane had admitted to continuing thoughts of suicide. She talked about her recent suicide attempt where she had overdosed on a supply of medication she found in their medicine cabinet. She sought help immediately afterward by phoning her husband Craig and informing him of what she had done.
Jane said "I think that overdose was really my way of saying – look, you’re not getting it. Something is really wrong. I was hoping it would make them stand back and think – gosh something is really wrong with Jane. She is really ill, she needs help."
Jane and I came to the conclusion that her motivation for the suicide attempt was the 'desire to communicate’ referred to earlier. At this stage we explored what she had been trying to communicate to Craig and her family over the past few months. Jane reported that she had been feeling guilty about being so low but had not talked openly to her family about this. She said that up to now she had felt that being depressed was just a matter of someone not 'pulling their socks up.’ Recognising Jane’s 'communication’ motivation, we brain-stormed ways other than suicide of effectively getting across to her family how she was feeling.
Another priority at this stage was to develop a 'Personal Self Harm Management Plan’ with Jane and Craig. This constituted a written list covering the following items:
Another technique I used with Jane at this time was the 'ABC Diary’. She recorded situations when she felt suicidal (Activating events); what she was thinking (her Beliefs about the activating events) and how she was feeling or what she did (her emotional and behavioural Consequences). She was to bring this diary to each session for review and discussion.
With regard to assessing Jane’s level of self-harm risk, I considered a number of factors as well as the 'communication’ motivation described earlier. On the negative side (1) she felt guilty; and (2) had a hopeless view of the future. On the positive side: (1) there was no family history of suicide or mental illness; (2) she was happy for Craig to be involved in her treatment; (3) she had current suicidal thoughts but no plan.
My assessment at this stage suggested that Jane was relatively 'safe’ to remain at home and for treatment to continue on an outpatient basis. If I had felt that Jane was 'not safe’ I would have asked for a psychiatrist review (and if needed, utilised the Mental Health Act for this to be carried out). Jane and Craig were both aware that hospitalisation and possibly the Mental Health Act were an option should Jane’s condition worsen.
My intention was to assess Jane’s self harm risk in every contact I had with her and intervene appropriately in order to maintain her safety. I was aware that her suicide risk might increase as her depression improved (when people are deeply depressed they lack the energy and motivation to do much about anything; but as their mood lifts, they can go through a stage where they develop the energy to carry out their suicidal intentions).
Education about depression
The next step was to provide Jane and Craig with some education about what depression is, the signs and symptoms, and the CBT approach to treatment. Jane was happy for Craig to be involved in an educational session in which I presented basic information and handed out written material to them both.
Dealing with uncertainty about medication
At this time Jane and Craig were pondering the issue of antidepressant medication. I encouraged them to write down, from their point of view, the advantages and disadvantages of medication. This resulted in the following list:
Together we challenged and disputed the disadvantages. I pointed out that addiction to antidepressant medication is highly unlikely, and that side effects usually pass after a week or so. We used the 'double standard’ technique on her 'failure’ belief. Jane shared how her friend Trisha had suffered a major depressive episode two years ago and had been successfully treated with antidepressant medication. I was able to point out that Jane’s approval of Trisha’s use of medication versus her own belief that it would represent 'failure’ showed she was operating on a double-standard.
Increasing activity level
One of Jane’s initial concerns was the fact that she 'wasn’t getting anything done’ and found it very difficult to cope with the demands of daily living: "I don’t want to do anything. I can’t do anything. I just can’t get motivated."
I explained to Jane that I would help her plan how she would spend her time between our sessions. I asked her to begin by monitoring her activities, documenting them on an hourly basis and rating each activity 0-10 for pleasure and for mastery.
Once she had completed her activity record, we were able to see where there was scope for Jane to modify her daily schedule to make it more active and satisfying. The next step, therefore, was to turn the 'activity record’ into an 'activity schedule’, where each day was planned in advance on an hourly basis. Jane would continue to rate each activity for pleasure and mastery. This was designed to achieve two goals: (1) to gradually increase Janes activity level and to maximise her mastery and pleasure, and (2) to help Jane see that she was gradually achieving more and increasing the amount of pleasure she got from her activities (depressed people often find it hard, in the early stages of treatment, to acknowledge they are improving – recording hour-by-hour changes can provide 'documentary evidence’).
I talked to Jane about the importance of doing things before she feels like doing them, and that she doesn’t have to do anything to a high standard – she just has to do it.
We also talked about the therapeutic value of physical exercise. Jane had, in the past, been an enthusiastic runner but this was the first activity that disappeared as her mood dropped. She explained that she used to run early in the morning before the children got up, but she now felt so 'terrible’ in the mornings that going for a run would be impossible. When we explored this idea further, Jane agreed that the evidence indicated physical activity has a positive effect on depression. She agreed to start running again, but thought she would be more successful if she ran in the early evening once her children were in bed, as her mood generally lifted toward the end of the day.
Another very important part of Janes activity schedule was social interaction. As her depression had worsened, Jane had increasingly avoided adult company. She no longer engaged in 'social chit-chat’, even though she had always enjoyed this in the past. Accordingly, we planned some 'social’ time into her daily schedule. For example, she would phone one friend a day for a chat, and remain at kindy for one session per week and talk to three other parents in that time.
Gaining control over worrying
During our treatment sessions Jane talked about constantly worrying: "I worry about my illness and the effect on my family all day. The thoughts go round and round in my head all the time."
To help Jane deal with the constant worry, I introduced her to the technique of 'stimulus control’ (Froggatt, 1998). Jane was to postpone her worrying until a set time each day, writing down the worries in a notebook as they occurred during the day, then distracting herself by getting actively involved in a task or activity. She was to review the 'worries’ in her notebook at the set time, which for her was after the children were in bed each evening. As I anticipated, when she had her nightly 'worry session’, reviewing the worries she had recorded during the day, Jane realised that most of them were non-issues. For the items that did need attention, Jane problem-solved on these with Craig.
Developing enlightened self-interest
Before long we began to address Jane’s belief, identified earlier, that she should always put others before herself. "I was brought up that way. Mum always put us kids first – she never did anything for herself." The core belief that we uncovered was: "It is selfish to put my own wants before those of others."
I showed Jane how to dispute this belief, using the pragmatic, logical and empirical strategies outlined by Kopec et al (1994). Jane developed a new rational belief: "Time for myself is just as important as time for anyone else."
To help Jane develop a philosophical foundation for this new belief, I introduced her to the concept of 'enlightened self-interest’ (Froggatt, 1993). This concept is based on the principle of looking after one’s own interests, while taking into account the interests of those around
To put this into practice, we developed some 'stepping out of character’ homework which involved Jane indulging in a personal treat each day. Initially we involved Craig as Jane wanted his approval for this, but as time went on Jane was able to simply tell Craig what treat she had arranged for herself. Treats included such things as taking a luxury bubble bath, buying a bunch of flowers, reading a novel for one hour (undisturbed), going out for coffee with a friend, having a massage.
Self help work (homework)
A central feature of CBT is self help work. This is the work done by the client between therapy sessions and is a key reason why CBT is so effective and efficient in achieving deep and lasting change in a short period of time. Over the time we worked together, Jane carried out the following homework assignments:
Development of homework assignments followed some general principles:
The end of therapy
I prepared Jane from the outset for the end of therapy by discussing the likely time scale and number of sessions involved. As her condition improved we gradually reduced our sessions to weekly, fortnightly and then monthly.
As part of my evaluation of the effectiveness of our therapy I clarified with Jane whether improvements in her mental state were due to internal changes in her dysfunctional thinking (which would enable her to manage her moods in the long-term) or simply due to fortuitous changes in her external circumstances. Signs that she had made effective changes in her dysfunctional thinking were:
We discussed the fact that depression can reoccur and devised a self help plan. We identified Jane’s early warning signs of relapse: increased tearfulness, lack of confidence in being able to cope, sleep disturbance, increased negative and irrational thoughts, increased irritability toward the children and worrying thoughts. Preventive strategies Jane would put into place included:
As part of this plan we discussed Jane’s views on asking for help again should she need it and the key irrational belief we identified was: "I will think I am a failure if I come back for more help." Jane did a rational self-analysis on this, and developed the a rational alternative belief: "Relapse would not mean I am a failure – it would mean that I am human."
CBT is an ideal feminist therapy for a number of reasons. It deals with women’s problems in a comprehensive way that produces changes in their attitudes, feelings and behaviour. It teaches women a practical self-help method for challenging their self-defeating thoughts in regard to external situations so that they can take greater control over their personal lives, their emotional reactions and their careers. By first assuming better control of their thoughts, feelings and behaviours, women will be better placed to bring about the demise of oppressive institutions and take direct control over their lives.
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