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A therapeutic road map for effective treatment
By Margaret Wehrenberg
Psychotherapists probably see more cases of depression than anything else in their practices, but it remains one of the most challenging conditions to accurately assess and treat. Part of the problem, no doubt, is that "depression" is a broad, poorly defined diagnostic category, which embraces a daunting range of symptoms, including cognitive and physical lethargy, mental rumination, loss of concentration, chronic negativity and pessimism, feelings of worthlessness, and unremitting sadness. Furthermore, the symptoms themselves can block response to treatment. Lethargy, hopelessness, negative thought patterns, and refractory negative mood all interfere with useful interventions. To get beyond or around the powerful drag of inertia in depression, therapy needs to quickly nudge clients into action, help them take charge of their cognitive habits, instill hope, and reduce negative mood.
Rather than seeing depression as some kind of monolith, I've found it useful to see depressive symptoms as falling into four basic clusters, each reflecting a different underlying cause—neurobiological, traumatic, situational, and attachment related. By immediately addressing the attitudes and distinctive vulnerabilities that lie at the core of each cluster, treatment can begin to bring about a shift in brain function that makes longer term work easier. In what follows, you'll find a brief description of how to begin treatment with each cluster, with a particular emphasis on how to enhance the likelihood of initial engagement.
People who complain of low cognitive energy—"I just can't think about that now," or "I just sit and look at the work"—and persistent negative mood, irritability, and limited pleasure or interest in daily life are most likely suffering from endogenous depression, a condition assumed to be biologically, and probably genetically, based. They tend to be passive and unmotivated: their attitude toward therapy can be summed up as "What's the use?" Despite the neurochemical factors implicated in their depression, you can still nudge these clients into a more active, positive state of mind by engaging their power to make small decisions that will briefly override their low energy. By deliberately shifting away from their negativity and consciously acting in opposition to it, they can begin to make changes in their lives to provide just enough positive reinforcement to boost them a little way out of their trough of despondency.
Angel had suffered from depression most of her life, and had to exert tremendous energy just to get through a day of doing a minimal amount of housework and taking care of her child. She berated herself for being so unpleasant and bad-tempered to people. "Kindness is a fatality of depression!" Angel exclaimed, telling me how short and critical she'd been to her mother the previous week. She still felt irritable and guilty about it.