Counselling for Depression

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Paul Gilbert

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  • Counselling in Practice

    Series editor: Windy Dryden

    Associate editor: E. Thomas Dowd

    Counselling in Practice is a series of books developed especially for counsellors and students of counselling which provides practical, accessible guidelines for dealing with clients with specific, but very common, problems. Books in this series have become recognized as classic texts in their field, including:

    Counselling Couples

    Donald L. Bubenzer and John D. West

    Counselling People with Communication Problems

    Peggy Dalton

    Counselling for Eating Disorders

    Sara Gilbert

    Counselling for Anxiety Problems

    Richard Hallam

    Counselling for Grief and Bereavement

    Geraldine M. Humphrey and David G. Zimpfer

    Counselling for Stress Problems

    Stephen Palmer and Windy Dryden

    Counselling for Psychosomatic Problems

    Diana Sanders

    Counselling for Alcohol Problems

    Richard Velleman

    SAGE is pleased to announce second editions of the following:

    Counselling Survivors of Childhood Sexual Abuse

    Claire Burke Draucker

    Copyright

    View Copyright Page

    Preface to the First Edition

    Cognitive therapy began in America some thirty years ago. Since that time, it has seen enormous developments in the client groups treated and in its therapeutic approach. Two areas that have seen important changes to the early formulations are a renewed focus on the therapeutic relationship (e.g. Beck et al., 1990; Safran and Segal, 1990) and an increased focus on interpersonal cognitive processes (e.g. Bowlby, 1980; Liotti, 1988; Safran and Segal, 1990). Both these concerns are a main focus in this book. In 1988 Trower et al. published Cognitive-behavioural Counselling in Action. They outlined the basic techniques and issues of the cognitive approach. The present volume, for the ‘Counselling in Practice’ series, is designed to build on their introduction. It explores interpersonal counselling with a particular client group – depressed people.

    The aims of this book are to focus on the interpersonal themes in counselling depressed clients, including those of the therapeutic relationship. The book is divided into two sections of four chapters each. Chapter 1 addresses issues of the nature of depression and the therapeutic relationship. Here I try to capture something of the nature of the depressive experience and focus on important counsellor skills. Chapter 2 explores the central issues of interpersonal approaches, the basic domains of relationships and how these are affected in depression. Chapter 3 outlines the basic premises of the cognitive approach and why cognitive counsellors are particularly concerned with the construction of internal meaning, ways of attributing causes to things, and basic attitudes and beliefs. Chapter 4 explores the many ways of conceptualizing therapeutic interventions and challenging dysfunctional thoughts and attitudes.

    The second section aims to build on these concepts, and lead the reader through a step-by-step approach to the process of counselling the depressed person. Counselling scenarios are given to illuminate specific points and highlight types of intervention. Most of these scenarios are not derived directly from taped interviews (although some are) but from notes made at the end of sessions. They are not meant to represent exact scenes but rather to indicate and highlight issues. All client names have been changed, and minor alterations introduced in the history, to avoid identification. Chapter 5 outlines the issues that arise during the early parts of the therapy, and how to engage and agree shared understandings and goals of counselling. Chapter 6 explores the kinds of issues that arise in the middle of counselling, as the counsellor and client engage in deeper explorations and seek opportunities for change. Chapter 7 looks at some special problems that arise in depressed clients. Special attention is given to shame, guilt, envy and idealizing which often figure prominently in depressive experience. Chapter 8 explores termination issues and offers some personal reflections.

    Preface to the Second Edition

    In the time since I wrote the first edition of Counselling for Depression things have changed, including gaining more experience in working with depressed people, who are the greatest teachers. Also our own research efforts on submission, escape and defeat behaviour have been illuminating in a number of ways (e.g. Allan and Gilbert, 1997; Gilbert and Allan, 1998). For example, we have found that many (but by no means all) depressed people feel unable to escape from the things that cause them pain. These may either be their relationships, dashed hopes and aspirations, relationships or physical illness. Depressed people can suffer a constant bombardment of negative thoughts, feelings or conflicts, from which escape seems impossible. So they often feel defeated and overwhelmed by their negatives. Therapy can help reduce that bombardment and help the person develop more internally supportive relationships, more helpful coping behaviours, and elicit more support in the external world.

    The outline of the book is similar to the first edition but some chapters have been extensively re-written and updated and there is an extra chapter devoted to interventions. Chapter 1 discusses the nature of depression and the importance of various aspects of the therapeutic relationship. Chapter 2 has been re-written to accommodate new understandings and findings in research on depression. The typical backgrounds, themes of depressive thinking and various coping behaviours that often can be ineffective for depressed people are covered. Chapter 3 outlines some of the basic premises of the cognitive approach to depressive disorders and notes how depressed people tend to ‘dwell’ on various negative thoughts, feelings and negative scenarios of the future. Chapter 4 explores the different processes for cognitive behavioural interventions for challenging the various negative thoughts and behaviours. Chapter 5 offers insight into challenging negative cognitions in specific ways and in particular internal shaming cognitions. I also cover in more detail the importance of developing inner warmth.

    Part 2 begins with Chapter 6 which outlines some of the ways to begin the counselling process for the depressed person. Chapters 7 and 8 then focus on special issues that are likely to arise in counselling depressed people. Because this book is focused on interpersonal themes, these two chapters give examples of working with specific problems. Chapter 9 gives an overview of the types of interventions discussed, explores termination issues and basic therapeutic relational issues that can arise in counselling. In particular we will finish by exploring some of the beliefs and thoughts of counsellors when they try to help depressed people.

    This edition also contains new appendices to help guide you in identifying negative thoughts, questions to challenge them, and how to work with thought forms.

    As for the first edition, this book is not designed for people with no training or experience in counselling. We anticipate that people using these techniques will have undergone proper training in counselling and that the approaches outlined here can be weaved into their practice. Ideally this should be done with supervision from trained cognitive therapists. This book also gives a particular approach to counselling a depressed person. There are many excellent cognitive therapy books currently on the market and no one book can cover all of the basic principles and ways of working.

    This book is focused primarily on the interpersonal dynamics and interpersonal thinking styles of depressed people. This book is designed to take you through a form of counselling process step by step. It also offers some thoughts about how to deal with specific problems. It has not gone into detail about counselling couples or families, even though the book is concerned with interpersonal cognition. Again, this would be too much for one book and is better dealt with by those who are skilled in working and writing on depression in that way. You will note that the text has been updated with new references, which I hope will be useful for you to explore deeper into the depression literature. Working with depressed patients is always a challenge. Each person is unique, although depressed people will have many themes and issues in common. A book such as this can only be a guide that I hope will be useful to various therapists and their clients.

    Acknowledgements

    First Edition

    Special thanks go to the series editor, Professor W. Dryden, for asking me to attempt this endeavour, and his encouragement during the writing. His advice was, as always, invaluable. He worked hard on the manuscript, and tried to steer me away from obscurity and lapsing into evolutionary theory. Appreciation goes to Dr C. Gillespie for his support and advice, and his comments on various chapters. Many thanks also go to Susan Worsey and Sue Ashton, who both worked hard on the text. I am indebted to the many clients who, over the years, have shared their depressive experience with me and enabled me to learn from them. They have been the best teachers. Gratitude also goes to Nell Hadlow who helped to correct the manuscript and get it into readable form. Thanks also to Joyce Chantrill and Pat Gibbins.

    Second Edition

    The Southern Derbyshire Mental Health Trust and University of Derby have been supportive in setting up the Mental Health Research Unit which has aided our research into depression. Many thanks to them, especially Dawn Forman (Dean of Health & Community Studies) and Dorothy Lane, Director of Nursing and Human Resources (SDMHT). I am also grateful to Diane Woollands for her expert, efficient and supportive secretarial skills. And as always love and gratitude to my family and the many patients who continue to teach me.

    Dedication

    To Jean, Hannah and James, who love and support me, the many clients who have guided and taught me, and Professor A.T. Beck who got us all thinking cognitively and revolutionized the psychological treatment of depression.

  • Appendix 1: Typical Styles of Thinking

    Here is a quick review of typical depressive cognitive styles. They are written in a way that can be shared with clients. When people become depressed they tend to see themselves in negative ways. They may see themselves as failures, inferior or worthless, their relationships as unfulfilling and the future as rather black. These thoughts and beliefs are often maintained by particular styles of thinking and make depression worse. When we are depressed we look on the black side of things and overestimate dangers and setbacks. Some of the more common depressive thinking styles include the following:

    Jumping to conclusions When we are depressed we tend to jump to conclusions easily, particularly negative conclusions. For example, your friend is in an irritable mood so you conclude this is because she doesn't like you. The shop assistant gives you the wrong change and you conclude he/she takes you for a ‘soft touch’.

    Emotional reasoning Emotional reasoning is related to jumping to conclusions. This is when we go for ‘gut reactions’ to things: it is our first, immediate, emotional response. So if you get the ‘feeling’ that somebody doesn't like you, you assume that it is true rather than test the evidence for it. It is quite useful for both jumping to conclusions and emotional reasoning to practice generating alternatives. Do not assume that your emotions have necessarily given you an accurate view of the world.

    Discounting the positive When we get depressed it is very easy to discount our positives. We are not able to focus on things we do have, only those that we don't. Discounting positives is often related to disappointment in not being able to achieve exactly what one wants. Even when people who are depressed achieve things they tend to discount it with the idea that ‘anyone could do that’ or ‘I used to do so much more when I wasn't depressed’. However, remember overcoming depression is a step by step process and if you continually discount your positives it is going to be difficult to start moving up the ladder.

    Disbelieving others When we become depressed it is very common to believe that others are only being nice because they want to appear good themselves. Depressed people often believe that individuals have one set of thoughts that they express outwards and a set of thoughts that they keep private. Depressed people and socially anxious people worry that the private thoughts of people are very negative towards them. Again, however, it is important to explore this and not take it for granted.

    Black and white thinking When we become depressed it becomes less easy for us to think about life in complex ways. Therefore we tend to become very black and white, that is ‘either or’ in our thinking. Either we are a success or we are a failure; either this relationship is good or it is a complete failure. It is useful to remind ourselves that most things in life are a bit of this, a bit of that, a bit of good, a bit of bad, a bit of black, a bit of white, rather than absolutes. When we become depressed we can forget this. So try thinking in shades of things; a bit of this, a bit of that. If you are thinking about relationships focus on the things that you like about them and things that you prefer as well as the things you dislike and try to conceptualize this as a complex mixture of different things rather than all good or all bad. Indeed, try to avoid using terms like good or bad. They, in themselves, imply that such things can exist, in an absolute way – which is rarely the case.

    Self-criticism We may become depressed because we are disappointed in the way things have gone, for example how we look, or maybe achievements haven't worked out, or relationships haven't gone so well. We can become quite frustrated. This frustration can sometimes turn in on the self as if we believe that ‘if only I had been different, looked different or behaved differently then everything would have worked out fine’. Self-criticism often generates negative emotions, particularly anger towards the self and this increases the ‘stress’ on your stress systems. That in turn will continually fuel the depression. One of the key things to learn is how to be less self-critical, and take the emotional sting out of the self-criticism. Learn to be caring and nurturing when times are hard or when you are disappointed. If you learn to develop a friendly attitude to yourself when things go badly this is going to put you in very good stead to be able to cope with the roller coaster ups and downs of life.

    For more information on cognitive distortions and how to combat them see Gilbert (2000) Overcoming Depression.

    Appendix 2: Sample Case Formulation Sheet

    Early history (key relationships and meanings given to them)

    Sees self asSees others as

    Depressive attitudes and rules for living

    Key social behaviours that can maintain depression and/or increase vulnerability

    Typical negative automatic thoughts and depressive thinking styles

    Current symptoms

    Appendix 3: Some Useful Challenges to Negative Automatic Thoughts

    When challenging negative styles of thinking it is useful to keep in mind that you will want to avoid pitting yourself against your clients – getting into unhelpful debates. So you will need to explore with your clients what they can come to challenge and question and teach them how to challenge their own thinking. Some useful questions for this might be:

    What is the evidence that supports your belief and what is the evidence that may not support it?

    If you look at this event again is there anything you might be excluding or not focusing on?

    How would you typically seek this if you were not depressed?

    What alternatives might there be to this view?

    What other explanations can you think of for this event?

    What kind of thoughts would help you cope with this at the moment?

    How would you like to see this, which helps you to control your depression?

    How might you see this event in (say) six months’ time?

    How might we take a more complex and varied view of this?

    If you had a friend, how would you help them see this?

    How would you like someone who cared about you to help you see this differently?

    If your thoughts were warm and compassionate, what would they be?

    What are the advantages and disadvantages of thinking about this difficulty in this way?

    What are the advantages and disadvantages of changing the way you think?

    What are the fears of changes?

    What do you see as your greatest blocks to change?

    How could we break this problem down into smaller, step by step problems?

    How could we generate step by step approaches to this difficulty?

    If you overcame your depression, how might you look at this situation?

    What might one learn from changing negative thoughts?

    Appendix 4: Thought Monitoring and Challenging Form

    Below are two worked examples using one particular thought form.

    None
    None
    None
    Writing Things down – Why This is Important

    It is important for cognitive counsellors to really get familiar with the procedures of writing things down. It is usually not enough for clients to simply understand the principles of challenging their negative thoughts and to do it in their heads. The reason for this is that the client won't spend enough time focusing on their thoughts and their efforts at challenging are likely to be arbitrary and haphazard. The importance of writing things down include:

    Writing down and slowing down Helping patients to learn to write down their thoughts also helps them slow down their thoughts. This can be extremely important both for thought catching and for challenging.

    Thought catching By slowing things down and helping people really focus on what is going through their minds they may be able to recognize all kinds of meanings and thoughts which would not become fully conscious had they not taken the time to try and write down their key thoughts. In other words, clients have to ask themselves questions such as ‘how do I explain this feeling to myself?’ ‘how can I account for what I feel?’ the more clients learn to do this the better they will be at thought catching.

    Attention Writing down also provides an opportunity to focus and attend to the issues at hand. This attentional focusing is again an important function of cognitive therapy.

    Gain a new perspective Seeing thoughts written out in front of the client may help them to see that their depression is pushing them into overly negative positions where they are losing perspective. Having things written in front of them allows clients to stand back and view it from a slight distance.

    Thought challenging Writing down is also very important for exploring thought challenging. Firstly, it helps the client to focus on ‘point by point’ challenges such as ‘what is the evidence’, ‘what might an alternative view be’ ‘what might I say to a friend?’ If they have a list of challenging questions on the form in front of them then they can try to write out the alternatives to their negative thoughts.

    It is important therefore that clients should be educated into the importance of slowing down, writing down, spending time working on challenging the way they think rather than trying to do it quickly and rush through it. It is also important to help clients recognize that there is a distinction between those automatic thoughts that pop into the mind very rapidly and the kind of thoughts that they dwell and ruminate on. The ruminative thoughts are particularly important for depression.

    What Type of Thought Form?

    If you have read a number of books on cognitive therapy you will probably recognize that there are many types of thought form that you can use with your clients. It is very important that you understand the purpose of thought forms rather than to try and use forms off the shelf simply because the book says so. If you feel proficient in your cognitive techniques then you may wish to read Treating Complex Cases (Tarrier et al., 1998). If you do, you will see a number of chapters by various authors tackling different types of problems where they will use a variety of thought forms. The reason for this is that forms should be designed to meet specific purposes – to do a job.

    My general advice here is to keep it simple. Use whatever thought form suits the issue and don't struggle with forms that are too complex, either for you or your client. The most basic thought challenging form is simply two columns, this is where between you, you write out the negative thoughts in one column and then practise challenging them in the other. For example, it might look like this.

    Negative ThoughtsChallenging Thoughts
    • I am feeling depressed and not able to do anything.
    • There is a lot of work piling up on my desk.
    It's true I'm not feeling at my best right now and there is a lot of work to do, however, let's try and do say five or ten minutes and see how much I can get through.
    Nothing I do is going to make a lot of difference.
    • If I am able to do a little, this will be better than doing none.
    • I am perhaps getting overwhelmed by thinking that I have to sort it all out in one go. That would be nice but it is not practical.
    • I am going to start my 10 minutes now. What have I got to lose by trying?
    Beliefs 80%Beliefs 40%

    Rate belief You will note at the bottom of the table that we can also rate how much a client believes in something they have written down. Some people find that if they learn to rate the extent of their beliefs they realize that their beliefs are not always black and white or if they are, then this is unrealistic. So as time passes they may begin to note that they feel more comfortable and believe more in their challenges.

    Make your own thought forms As long as you understand the principles of cognitive therapy (e.g. identifying negative thinking that maintains or worsens a depression, and the importance of learning to challenge negative thinking in a way that the client finds acceptable and understandable) then you probably won't go far wrong. For example, you may wish to write out thought forms which are focused on the advantages or disadvantages of a belief. You might want to write out columns that have a focus on negative self evaluative thoughts (or the attacking part of self), or make a thought form looking at things in the past in one column, and things now and in the future in another column (see page 103). You may want to help clients recognize their change in feelings after they have done thought challenging, in which case you would have three or four columns. This allows people to rate how much they feel their feelings have changed as a result of doing these challenging exercises. You might have a series of columns which are:

    Negative ThoughtsChallenging ThoughtsHow I Feel Compared to Before
    • I am feeling depressed and not able to do anything. There is a lot of work piling up on my desk. Nothing I do is going to make a lot of difference.
    • It's true that I'm not feeling at my best right now and there is a lot of work to do, however, let's try and do say five or ten minutes and see how much I can get through.
    • If I am able to do a little, this will be better than doing none.
    • I am perhaps getting overwhelmed by thinking that I have to sort it all out in one go. That would be nice but it is probably not practical.
    • I am going to start with 10 minutes now. What have I got to lose by trying?
    • Having done a little, I realize that it is difficult but not impossible. I certainly feel I have made a small amount of progress, perhaps not as much as I would like, but at least I am a bit further forward. I feel maybe 5 to 10 per cent less down.

    The thought form that has been supplied for you in this book (as given earlier in Appendix 4) is a very basic form, which can be used in many different ways. You may find it suits most of your purposes or you may wish to explore other kinds of forms. For example, Padesky and Greenberg (1995) in their book Mind over Mood, provide a number of other types of thought form that clients can use.

    If you are providing thought forms for clients to take away it is useful if they are accompanied by a series of questions for the clients to put to themselves to monitor and catch their thoughts, as well as a series of questions that they can put to themselves to challenge those thoughts. Appendix 3 gives a selection of such challenges that can be used.

    Some Useful Ideas

    It is important to fill in whatever form you use with the client together in the first instance, and to check that they understand it. When clients understand the principles, it can be useful to leave the client alone for ten minutes or so during an actual interview so they can practise doing thought forms themselves. Sometimes the counsellor's role is to provide opportunities for training and this can't happen unless the counsellor makes training opportunities available. If clients are having difficulties in doing thought forms on their own then leaving them in the room for five or ten minutes to practise by themselves can be a good way of helping them with that difficulty. One can then return to the room and see where their problems are in monitoring, challenging and writing down alternative thoughts. Explore how the client feels about this.

    It is useful to ask clients to bring their own thought forms to the counselling session. This allows a number of things. First, it enables you to monitor the progress of the patient and explore how they are doing in their challenging. Second, it makes clear that this is an expectation of therapy. Remember that the ‘shame of homework’ is always a possibility here (see page 90). Check that clients are not filling in their thought forms just before they come to therapy to please you and to prove that they have done ‘good homework’. Also remember that some clients will avoid doing homework or filling in forms in session because they are frightened of doing it incorrectly or being shamed by the therapist. It is therefore important to make sure that clients understand why they are doing this kind of work, take responsibility for it and are not carrying fears of being shamed for trying things out and experimenting (e.g. getting it wrong).

    One can also help patients to focus on how their behaviour would change if they really believed their alternative thoughts. Could they try this behaviour change for a morning or afternoon, a day or week? With all these interventions practice is important.

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