Q: Since the pandemic began, many of my clients are experiencing more symptoms of depression. What interventions work well in a teletherapy session?
A: Nearly everyone’s life has been turned upside down by the pandemic, and it’s not surprising that clients are feeling more depressed lately. I’ve noticed this especially with those who have a history of depressive disorders. Fortunately, Sensorimotor Psychotherapy offers several interventions that are easily transferred to video sessions. They can even help us therapists, who may be feeling the weight of our own challenges, in addition to those of our clients.
Lengthen the Spine
One of my favorite interventions for depression is deceptively simple—lengthening the spine. With the heaviness of depression, even with just the words I’m depressed, the spine tends to collapse. Try it yourself, and notice that when you say “I’m depressed,” your body reacts, even if you don’t currently feel that way. Because depression is such a physical experience, somatic techniques can be very helpful.
If you hear clients say the word hopeless, or if you see the collapse in their chests on screen, you can invite them to “notice what happens if you just lengthen your spine a little bit from the lower back up.” I always add, “Don’t sit up straight the way your mother might have told you—just lengthen your spine from the lower back up.” Usually, it’s not difficult for people to do this, and it’s interesting how effective something so small can be in the moment. We need interventions for depression that don’t require much effort because a depressed client won’t have much energy.
Another thing that can help depressed and anxious clients is orienting. Dogs do it all the time: when they start sniffing around a new space or person, they’re orienting to the environment through the sense of smell. Humans orient visually; those who are visually impaired often orient auditorily. But when we look around and notice where we are, it usually regulates autonomic arousal and brings our nervous systems up into window of tolerance.
An important tip from Sensorimotor Psychotherapy is to demonstrate to the client how to orient, making sure to turn your head and neck 180 degrees to model taking in the whole space. Words alone are harder to process, especially for depressed clients, whose nervous systems keep them slow and shut down.
I frame this intervention by asking clients to “just look very, very carefully around the whole room and tell me the one thing you like the least in this room.” And that invitation wakes them up. They brighten up and ask, “Is it really okay to tell you what I don’t like?” Then, after they’ve found one thing they don’t like in the room, I might say, “Good. Now could you look around again very carefully and find two more things that you dislike the most?” Because I’ve created novelty, suddenly their nervous system begins to have more energy, counteracting some of the heaviness and slowness.
Orienting and lengthening the spine represent somatic experiments. I love to add the Sensorimotor Psychotherapy technique of verbal experiments. Experimenting with words is important because they have such a strong impact on body experience.
If, as you’re reading this article, you say to yourself, “This is interesting,” you’ll notice a slight lift in energy: a smile might come up, or your eyes might light up a little bit. If you say to yourself, “This is stupid,” you might notice a drop in energy or a slight collapse in your shoulders.
To help clients appreciate the impact of their own words, we can ask them to notice what happens to the depression when they repeat words like, “I’m a hopeless case.” Then we can ask, “When you say those words, do you feel better? Or do you feel worse?” Most people say, “I feel worse.” That’s when we can ask them to notice what happens when they repeat the words, “I’m doing the best I can.” It’s important to add, “It doesn’t matter whether you believe them or not—see what happens when you just say those words.” Most clients report, “I feel a little bit better.”
If you have a depressed client who is numb and passive and has no energy or interest, don’t be afraid to use movement. I say to the client, “You know, I’ve been sitting all day. Would you mind terribly if we stood up?” Most hypoaroused, depressed clients are automatically compliant, so they’ll usually be willing to try it; and when they do, they feel slightly better. Movement might seem harder in these days of video conferencing, but we can still move. We can simply stand up in front of our computers, for example, and ask clients to do the same.
Talking about COVID-19 generally increases anxiety. For anxious clients, standing up and rocking from foot to foot while you mirror their movements can be soothing and regulating.
Dropping the Content
Here’s a simple Sensorimotor Psychotherapy technique for depressed or anxious clients who tend to ruminate on the same negative thoughts day after day, session after session, exacerbating their self-loathing and sense of unworthiness or their fears. After noticing out loud, “There’s that thought again about [. . .],” I ask them, “When you have that thought, do you feel better, or do you feel worse?” If they reply that they feel worse, then I can suggest, “Could we try something that might help?”
Once they’ve agreed to try it, I hold out my hand, palm up, and I ask the client, “Imagine someone putting a burning hot potato onto the palm of my hand. . . . What is my hand going to do?” I never ask them to put out their hands. Instead, I put out my hand so they can see and imagine the hot potato dropping into it. Then I make the dropping motion as if I’m trying to get rid of the potato as quickly as possible, and they often spontaneously make the same gesture, even if their hands are at their sides. Then I instruct them: “Every time you have one of those toxic thoughts, drop it immediately—just like a hot potato.”
It’s important to practice this technique in therapy. Whenever I hear clients utter a thought we’ve framed as toxic, I make the dropping motion to stimulate their making it, and slowly they begin to develop more awareness and control over their negative thoughts.
I’d like to add an important note here. During this time of isolation and crisis, our clients (and we ourselves) will frequently have negative thoughts and predictions. Those are normal to have in this situation, but they can amplify the stress involved in dealing with the crisis. We have to frame COVID-related thoughts differently, so we are not suggesting that it’s abnormal to feel anxiety and depression in a state of emergency. I might say, “As normal as it is to have those thoughts, they’re toxic for you. Let’s work on putting them aside, because that will support your immune system.”
Another option with depression and hopelessness is to frame them as communications from a “depressed part.” I ask the client, “Notice what happens if you assume that the depression belongs to just one part of you. . . . Does that feel better or worse?” Most people report it feels better.
The Fragmented Selves model—which integrates Sensorimotor Psychotherapy ideas with Internal Family Systems techniques—reframes depression and anxiety as expressions of parts, and we can help the client become curious about these parts. “How old might that depressed part be? Can you ask that part to show you a picture that might explain why she’s so depressed?”
When we frame depression or anxiety as a communication from a young wounded child self or from a part trying to warn us of dangers ahead, most clients instinctively have more compassion for themselves and can begin to relate to the depression as a feeling memory.
Remember that Change Stimulates “Turbulence”
If the depressive state was once a survival response, if a child’s safety depended on being seen and not heard, it can be triggering to begin to have that depressive state lift now. So remember that as the depression remediates, anxiety about visibility may increase, and more access to emotions may trigger feelings of overwhelm. My colleague Deirdre Fay talks about this phenomenon as “turbulence,” which normalizes the fear of feeling better. I quote Deirdre to my clients: “Don’t worry. When something changes, we experience turbulence. This is just turbulence. This is a lot to get used to. And you will.”
Use Your Social Engagement System
When clients are in a parasympathetic depressed state, we therapists have yet another avenue for intervention: our social engagement system. Stephen Porges describes this as a neural system that controls the facial muscles, the movements of the eyes and eyelids, the larynx for voice, the middle ear for listening, and the tilting and turning movements of the head and neck. Even over video, you can make use of your eyes, facial expressions, voice, and movements. You can soften your gaze and put a little sparkle in your eyes. You can also play with your vocal tone and pace of speech.
The more energy you can bring to the screen, the more the client is going to feel it. Play with what seems to get the client more engaged, more present, more relaxed, or elicits a little lift in mood.
I’m going to end with therapist Dan Hughes’s words, which acquire new urgency in the current pandemic: “The primary therapeutic attitude that we need to bring is that of playfulness, acceptance, curiosity, and empathy.” Therapists are really good at empathy and acceptance, but we forget to be playful. Playfulness is something people need now, and people with depressive disorders need it even more. Hughes says, “Playful interactions focused on positive affective experiences are never forgotten, and all communication is embodied within the nonverbal”—meaning you don’t say something if your body and your facial expression don’t back it up.
It might seem counterintuitive, but think about what could happen if you imagine helping clients have fun with their depression.
Janina Fisher, PhD, is a licensed clinical psychologist and instructor at the Trauma Center in Boston, a senior faculty member of the Sensorimotor Psychotherapy Institute, and a former instructor at Harvard Medical School.
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