Depression is a downward spiral. Find which path may break that cycle for you.
Researchers agree that depression is a downward cycle. Which path is most successful in breaking that downward spiral? There are at least four effective treatment approaches for depression, each assumes a different primary cause. Yet research finds them all equally effective. We saw this in a prior post, The Two Faces of Depression. That post showed that both the cognitive behavioral approach which emphasized the effects of problematic thinking, and interpersonal therapy which emphasized the effects of problematic relationships, were equally effective. Now, with four equally effective approaches, how do we find which is the best path to follow?
Many Paths to the Top
A familiar Chinese proverb suggests that “There are many paths to the top of every mountain; yet the view from the top is the same.” All approaches promise the same resolution (or re-solution to break the cycle). Similarly, some ancient Hawaiian traditions suggest that wisdom comes from many paths. Regarding enlightenment, it suggests that “There is not just one, or correct, way to find your answers. The path which will be most successful for you is the one that feels the most natural for you to follow.” Such cross-cultural wisdom also rings true as we look at the convergence of recent psychological research on psychotherapy.
Flexibility and Fit
An analysis of a number of studies has shown that, when clients receive their preferred approach to treatment, they have better outcomes and drop out of therapy less often than clients receiving treatments they do not prefer (Swift, Callahan, & Vollmer, 2011). Flexibility in approach is now emerging as a common recommendation for therapists and clients alike (cf. Owen & Hilsenroth, 2014; and the APA Presidential Task Force on Evidence-Based Practice, 2006). This flexibility includes such things as our culture, values, language, economic resources, social support, and a range of other factors. A coherent therapeutic approach that fits with both the understanding and investment of those seeking help and those practitioners seeking to help them is emerging as a powerful key to successful change across all problems and treatments.
Pillars of the Four Paths
Returning to the four equally effective treatments for depression, we find that each is built on a different pillar or assumption about the cause and resolution for depression. These four pillars are:
- Our thoughts
- Our relationships
- Our behavior
- Our emotions
The Path Through our Thoughts
Cognitive behavioral therapy (CBT) assumes that depression’s downward cycle moves through our thinking. Helping practitioners will partner with us to conduct collaborative experiments to check out how true our assumptions are about ourselves, our behaviors and our futures. Depressed people tend to develop a negative view of themselves, assuming that because of their presumed deficits, they are undesirable and worthless. This leads them to interpret ongoing experiences in a negative way, viewing situations as intolerable obstacles and confirmations of how bad things really are. These tendencies result in negative views of the future, anticipating that current difficulties or suffering will continue indefinitely. Aaron Beck’s (Beck et al., 1979) cognitive behavioral approach partners with clients to challenge typical sets of “thinking errors” such as
(a) Arbitrary inference, when a conclusion is drawn in the absence of evidence or in the face of evidence to the contrary;
(b) Selective abstraction, when a detail is taken out of context to characterize a whole experience, and ignoring other salient features of the situation;
(c) Overgeneralization, when one or more isolated incidents are used to draw a general rule or conclusion and apply it across broadly related and unrelated situations;
(d) Magnification and minimization, when perceived negative events or qualities are inflated and positive ones depreciated;
(e) Personalization, where a person relates external events to herself when there is no basis for making such a connection; and
(f) Absolutistic, dichotomous thinking, where all experiences are cast into one of two opposite categories.
As we check out the “error” or these and other assumptions, we collaborate with our practitioner to develop more “accurate” and positive pathways for our futures.
The Path Through our Relationships
The second path, as discussed in the last post, The Two Faces of Depression, is the interpersonal therapy approach. The interpersonal (IPT) approach to depression (Klerman, et al., 1984) locates depression in our interpersonal relationships. IPT suggests that psychotherapy should help us examine current interpersonal relationships and how they have evolved from experiences with figures in childhood, adolescence, and adulthood.
The interpersonal view suggests there are four main areas of interpersonal distress that may trigger depression. These interpersonal domains include:
(a) Grief, which focuses on the person’s reaction to the actual death of a person or people either now or in the past;
(b) Role disputes, which involves interpersonal disputes with friends, family, partners or co-workers;
(c) Transitions, which involve role-changing life events such as marrying, taking a new job, becoming a student, or becoming a parent and the like; and
(d) Interpersonal deficits, which relate mainly to interpersonal isolation and the poor quality and quantity of the depressed person’s interpersonal relationships.
The key element here is that the depressed person responds to each of these areas of interpersonal distress in a way that sets up a characteristic vicious cycle that eventually takes on a life of its own. The cycle eventually becomes an actual syndrome called clinical depression. One critical aspect of treatment is letting clients know that being depressed is no more their fault than having diabetes or a broken leg would be.
The interpersonal view suggests that the depressive symptoms are a natural result of failing to look at options to resolve critical areas of interpersonal distress and then take action to resolve them. The task for us when we are depressed and seek help is to sort out which of these four areas of relationships are most distressing and then devise a plan of action to resolve rather than to avoid or worry about them.
The Path Through our Behavior
Turning to a path focusing on our behavior, the behavioral activation (BA) approach to treating depression (cf. Dimidjian, Martell, Herman-Dunn & Hubley, 2014; Martell, Dimidjian, & Herman-Dunn, 2010) assumes that the downward spiral of depression involves growing withdrawal from enjoyable social activities. The more we pull away from and avoid our perceived unpleasant environment, the less reward we receive. The less we engage, the less skilled we become at engaging in what we truly value and desire. Turning inward and ruminating becomes a solution pattern that turns back on itself, making worse the very process we are trying to overcome. (Hence the importance of remaining active during a pandemic, for example.)
Reversing this pattern of inward turning avoidance becomes the key element of the behavioral activation approach. Once this pattern is discovered and agreed upon with our practitioner, we collaborate in breaking this downward and inward cycle by designing and engaging in sets of more rewarding activities. The basis of this approach is fundamentally behavioral as it increases positives in our lives.
The Path Through our Emotions
Emotion focused therapy (EFT) (Greenberg, 2002; Greenberg & Watson, 2006) is a fourth effective pathway through depression. This pathway focuses on emotional experiences of our past that eventually draw us into habits of withdrawing and avoiding similar experiences in our current lives. Problematic emotional responses become over learned reactions to repeated and/or intense emotional experiences, such as trauma, shame, rejection, humiliation, and so on.
Turning to resolving depression, Greenberg (2011) has said, “Paradoxically, one of the most effective ways of helping clients contain emotion may actually be helping them to become aware of it, express it, and decide what to do about it as soon as it arises. This is because suppressing an emotion and doing nothing about it tends to generate more unwanted emotional intrusions, making it more overwhelming or frightening” (p.72). In this approach, we are asked during sessions to put ourselves in situations where we confront our fears or others in our lives through dialogue with the imagined other in an “empty chair” for example to work through the emotional issues.
Depression is resolved (or re-solved) by doing the counter-intuitive thing and experiencing what we least want to do. In emotion focused therapy, it is experiencing the emotions that we have avoided. In behavioral activation, it is taking opposite action in the face of patterns of withdrawal, rumination, and inertia. The same goes for the cognitive behavioral path and the interpersonal approach as they reverse thinking and relationship cycles.
Which Path is Best?
Research finds all four paths equally effective in breaking depression’s downward spiral. Each takes a different direction in focusing on our thoughts, our relationships, our actions, or our emotions. Again, the best path is the one that makes most sense to all involved. In resolving depression, there are many paths to the top of every mountain, yet the view is the same–the downward cycle breaks and we can see brighter new horizons.
American Psychological Association. (2006). APA Presidential Task Force on Evidence-Based Practice. Washington, DC: Author
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press.
Dimidjian, S., Martell, C. R., Addis, M. E., Herman-Dunn, R., & Hubley, S. (2014). Behavioral activation for depression. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A sept-by-setp guide (5th ed., pp. 353-393). New Your, NY: Oxford Press.
Fraser, J. S. (2018). Unifying Effective Psychotherapies: Tracing the Process of Change. (Abstracted from Chapter 7, Depression). Washington DC: APA Books.
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington, DC: APA Books.
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression. Washington, DC: APA Books.
Greenberg, Greenberg, L. S. (2015). Emotion-focused therapy: Coaching clients to work through their feelings (2nd Edition). Washington, DC: APA Books.
Klerman, G., Wwissman, M., Roundsvile, B., & Chevron, E., (1984). Interpersonal psychotherapy of depression. New your, NY: Basic Books.
Owen, J., & Hilsenroth, J. J. (2014). Treatment adherence: The importance of therapist flexibility in relation to therapy outcomes. Journal of Counseling Psychology. 61, 280-288.
Swift, J. K., Callahan, J. L., & Vollmer, B. M. (2011). Preferences. Journal of Clinical Psychology, 67, 155-165.