# Book - Psychotherapy and Counselling for Depression 3rd Ed Paul Gilbert 2007 [[Depression]] # Part I Understanding the Nature of Depression with a Biopsychosocial Approach ## 1  Depression: The Basics 3 - [[Depression affects individuals across different aspects of functioning motivation, emotional, cognitive, behavioural, and biological.]] - [[Depression has multiple causes]] - [[How to diagnose depression]] - [[Suicide Risk Factors]] - [[How is treatment-resistant defined]] - [[What are the barriers to treating depression in counselling]] - Treatment includes taking a [[BioPsychoSocial]] approach - [[What are the factors contributing or prevent illness]] - the 4Ps conceptualisation - [[Recovery MOC]] ## 2  Multi-Level Systems in Depression 22 - People get depressed for different reasons. Again referring to the heterogeneity of illness mentioned in [[Depression has multiple causes]], [[Chapter 1 - The Study of Depression in the Frame of the New Research Paradigm in Psychiatry#^248014]] - I am reminded by [[Viktor Frankl]] - [[Book - The Will to Meaning#^3999db]] - (My notes: Although different patients might have similar diagnoses, but the cases of their symptoms are different. ![[Screenshot 2023-07-16 at 9.51.28 AM 1.png]] - **We need to have a multidimensional perspective and remember that each depression is unique to the individual. There is no one-best-approach.** Each see in parts. - "Not only are there different types of depression, with different pathways into it, there are also many different theories and therapies for depression (Power, 2004). To the beginning therapist and counsellor this can be confusing. So how does one decide the best approach? One way is to look at research evidence for various types of therapy, which is the approach taken by various national guideline groups. Although obviously important, there are dangers to this if we lose track of the fact that each depression is unique to the individual." - Various researchers, and theorists have looked at the different levels and domains that implicate depression; from memory, cognitive, reasoning. etc - The author organised his view about the mind into four domains or functions (Gilbert, 1984, 1989, 1993, 1995a, 2005a). There are: (Page 25 - 43) - 1. Basic threat and safeness processing. - 2. Role-seeking and forming. - 3. Symbolic and meta-cognitive abilities. - 4. Identity-forming that depends on abilities for certain types of self-awareness, and which gives rise to a sense of self ‘who is’, ‘who can’, and ‘who wants to be ## 3  The Brain, Threats and Depression 47 * **Emotion is a signal, a warning about the environment**. - **Don't see mood as a problem but as a helpful guide. - **The threat of losing control**. - "Research on moods and emotions suggests that they provide important sources of information that guide behaviours, attention and subsequent thoughts (Izard, 2002)." - "We now know that: (a) emotions and moods influence information processing, especially the assessment of threat and safeness, and (b) research has shown that certain types of threat are major regulators of mood and emotions." **We need to validate and acknowledge our emotions, it is telling us something** - The threat of losing control, - Frustration - Stress - "hypothalamic-pituitary-adrenal system (HPA)", Cortisol - Stress - depression - Chronic Stress - Cortisol is an important hor- mone released at times of stress but it also circulates in the body all the time in 24- hour cycles or waves - Unfortunately, prolonged stress elevation of cortisol is bad for us. It is bad for the immune system and can cause undesirable changes in various brain areas, which affect memory, other cognitive functions and emotions (Bremner, 2002). - may actually cause shrinkage in certain areas such as the hippocampus and frontal cortex (Sapolsky, 2000) - The loss of Control: Helplessness - Learned helplessness theory. - Seligman (1975, pp. 53–4) reasoned that: When a traumatic event first occurs, it causes a heightened state of emotionality that can loosely be called fear. This state continues until one of two things happen; if the subject learns that he can control the trauma, fear is reduced and may disappear alto- gether; or if the subject finally learns he cannot control the trauma, fear will decrease and be replaced by depression. - Incentive Disengagement **- The brain telling you to give up, since effort not rewarded.** - incentive disengagement theory (Klinger, 1975, 1993).uggests that ‘depressed activity’ serves the function of disengaging an animal from unobtainable incentives and goals (i.e. to give up) - **Brain lowers the mood, to stop us from doing whatever that is not working.** - Nesse (2000; Nesse and Williams, 1995) has developed this view into resource allocation theory. He suggests that depression (which is a form of demobilisation) has no single function but that mood tracks the propitiousness of situations in order to adjust resource allocation (e.g. energy and investment – thus activity in the drive systems) in activities so as to maximise long-term pay offs. - Blocked and ineffective defences - Poor coping behavior. - To cut a rather long and complex story short, as people become depressed they tend to engage in less external problem-focused coping and focus on trying to control internal painful emotions. - p54 - For this reason problem solving and solution-focused therapies, such as breaking down problems, going one step at a time, engaging rather than avoiding the problem, or learning new skills to deal with problems, are often helpful for depressed people. - p54 - Blocked escape and entrapment - **People feel trapped. Stuck in their situation without any way out. These can increase the risk of suicide** - For example, a person would like to leave a neglectful or abusive spouse or a job but for economic reasons, guilt, fear of the spouse’s reaction or fear of aloneness they are unable to leave. A sense of being stuck in an undesirable situation and not being able to move from it is more common in depression than is sometimes recognised. Brown, Harris and Hepworth (1995) have shown that entrapment is a more powerful predictor of depression than loss alone. In a major study, Kendler, Hettema, Butera, Gardner, and Prescott (2003) also found that entrapment was significantly linked to depression. Gilbert, Gilbert and Irons (2004) found that entrapment was a common experience in depression and depressed people often ruminated and fantasised about escaping (although less commonly made plans to do so). - Indeed, Baumeister (1990) referred to suicide as a kind of escape from the self (see also Williams, 1997). There are also many clinical observations that when very depressed people make the decision to kill themselves, and they feel sure the pain will end and that they can get away, then their mood lifts. Indeed, it is clinically important to spot an unexpected shift in mood in some depressed people for this can indicate the person may intend to kill themselves. - ==How to help people get unstuck?== - Need for Space - A common theme is a need for space. - Either taking a short break, vacation, .. "get away" - Arrested fight and anger - **Anger, irritability can be a sign of depression. Because they can't express that anger outward, it becomes directed to self.** - There is a good deal of evidence that many depressed people experience increases in their anger and irritability (Gilbert, Gilbert and Irons, 2004; Riley, Treiber and Woods, 1989). However, again this anger may be either arrested (not expressed) due to a self-identity concern (anger is bad or shameful), fear of others’ responses, wanting to protect others, or, if it is expressed, it is too aggressive, ‘tantrum or rage-like’ (rather than assertive) or ineffective and can make things worse. - Some depressed people are unaware of their anger, are frightened of it and have learnt to avoid processing it – it is non-conscious to them. We will explore examples later in the book. For all such anger difficulties, working with their anger may be important (Gilbert, 2000a) - [[C202005142045 Anger can turn inward to become depression]] ![[Screenshot 2023-07-16 at 6.06.33 PM.png]] ## 4  Behavioural Approaches: Action Matters 63 ## 5  Human Social Needs and Roles: Attachment, Social Connectedness and Defeat 80 ## 6  Thinking, Self-Awareness, Social Goals and the Role of Shame in Depression 112 # Part II Processes for the Therapeutic Journey 145 ## 7  The Therapeutic Relationship and Working Alliance 147 [[17-07-2023]] - - Four possible ways therapeutic relationships exert their impact **Therapists create safe space for patients to explore their inner world** - Zuroff and Blatt (2006) outline some possible routes by which the therapeutic relationship exerts its impact. **Psychodynamic approaches, it is what goes on within the therapist during the session that is crucial for change. By picking up transference and countertransference** - A second view, common to psychodynamic approaches, is that it is what goes on in the mind of the therapist, as they engage the mind of the patient, that is crucial to change. Especially important is the therapist’s ability to be aware of the reactions that they trigger in their clients (transference) and what emerges inside themselves (countertransference). These are seen as pointers to the client’s difficulties. How the therapist works with these dynamic interactions and co-constructions affects the emergence of unconscious material and thus insight and progress. **CBT approach, therapist and client form a collaboration, to enable new learning to take place that stop unhelpful patterns** A third view, more common to cognitive behavioural therapists, is that the therapeutic relationship is important because a trusting and helpful relationship sets the platform for collaboration on the tasks of therapy. The ‘potent’ aspects of ther- apy are in the new learning (e.g. via understanding thought–emotions links and practising thought change, engaging in behavioural experiments, exposure, and practising anti-rumination strategies). ### Create Safeness and a safe base. ### The process ### Qualities of the therapy relationship ## 8  Beginning the Therapeutic Journey with the Depressed Person 172 1. Building trust and creating safety for the client 2. Exploring the story 1. Problem definition 1. **Problems usually have both external and internal. i.e External event trigger internal feelings** 2. ![[Screenshot 2023-07-18 at 7.36.37 PM.png]] 3. **Pace with the client. Don't rush in with techniques. Empathy is key.** 1. "This is a rather common theme in depression and tells the story about feeling mis- understood and not receiving empathy from loved ones. Here we see the client oscillating between ‘I’ve messed it up’ and ‘She doesn’t want to listen’. The coun- sellor should also be alert to the possibility that the client may fear that the coun- sellor will turn out to have a similar attitude (i.e. they won’t really listen, or will not become an ally). This theme needs empathic handling. If one rushes in too fast with techniques, the client can get the idea that ‘Just like others, the counsellor thinks I am being irrational or neurotic’." 4. **Take a full history. Understand the person.** 1. 1  Relationship with mother. 2. 2  Relationship with father. 3. 3  The relationship between mother and father. 4. 4  Relationships with siblings. 5. 5  Peer and school relationships. 6. 6  Early dating relationships. 7. 7  Marital relationships. 8. 8  Relationships with children. 9. 9  Other significant relationships (e.g. with grandparents, uncles, aunts or teachers). 10. 10  Relationships with peers. 11. 11  Work history. 12. 12  Major hobbies and sources of enjoyment. 13. 13  Major ambitions and life goals. 14. 14  Typical ways of coping with stress. 15. 15  Major life events in the recent past and earlier. 5. **Constantly look out for two things, Repetitive Patterns and Meanings, attitudes and beliefs surrounding those relationships** 1. *As you move through the life history, you will be constantly checking on two things. First, repetitive patterns (e.g. of rejection, neglect, abuse or over-protection, or needing to look after significant others). Second, you are interested in meanings, attitudes and beliefs that may have developed in these relationships by asking questions such as: What did you make of that? What did that mean to you? What sense did you derive from that? What did you conclude from that?* 3. **Working in the Present. (Process vs Content) 4. **Setting therapeutic goals and developing the therapeutic contract.**** 1. Hypothesising "what would be helpful". 2. Remember, compliance is not the same as collaborative work. **5. 5. Explaining the therapeutic rationale**** 1. The counsellor introduces the client to the rationale of their approach. **6. Increasing awareness**** 1. By explaining to the client the inference chain, or rationale, the goal is to increase client's awareness. **7. Moving to alternative conceptualisations** 1. Unpacking, reframing, loosening the knot, finding another perspective. Re-attribution training. 1. **Monitoring internal feelings and cognitions and role enactments**. 1. Patient now takes this new awareness to monitor moments outside of therapy when the coping habits get triggered. ## 9  Thoughts, Beliefs and Safety Strategies: Constructing Formulations 192 ## 10  Helping People Engage and Change: Some Basic Principles 223 [[Self Awareness, Metacognition, Recovery]] - Self-monitoring, Mindfulness and the observing self - Page 229 - Self Monitoring as an investigation - personal diaries, logs and journals. - Increasing self-awareness![[Screenshot 2023-07-18 at 8.03.35 PM.png]] - Non-verbal behaviour - Fantasies - Video play - Role Play ## 11  Developing Self-Compassion 241 - Compassion can be scary for those who have not experienced it before. Their desire to seek self-soothing trigger threat system - One way of thinking about this is that the soothing system has become conditioned with threat signals. Feelings of kindness and warmth emanate from the social attachment system and when we activate these feelings we are activating this system. Recall that Ferster (1973; see also Chapter 4) pointed out that one emotion could become a condition stimulus for another. Hence children’s care- eliciting feelings and desires for self-soothing (if they were frequently punished) could become conditioned to aversive emotions. It certainly seemed as if, for some people, trying to activate feelings of self-soothing triggered threat systems. - Acknowledging positive emotions and needs also brings up negative memories and emotions. So people learn to cope by numbing themselves. - Another theme to emerge in discussion with depressed people was that when they began to acknowledge feelings of warmth, kindness and desires to feel safe this opened up a set of emotional (attachment) memories that were filled with feelings of sadness, abandonment and aloneness. These feelings produced extraordinary and powerful feelings of grief which they had spent a long time trying to keep at bay. For example, Jane had been adopted early in her life and her adopted mother was harsh and critical. When Jane began to do kindness-focused work she had a spontaneous memory of having been beaten by her mother and laying on her bed looking at the stars imagining her biological mother coming on a chariot to rescue her. Over the years she had learnt to avoid these feelings and memories because they over- whelmed her with sadness and aloneness. - People may believe that they don't deserve to be off the hook, if they are kind to themselves, they will become weak and vulnerable. - Another level with difficulties to the soothing system is related to people’s beliefs about being kind, warm and compassionate to themselves. Some people, for example, believe that they don’t deserve to be kind to themselves: it is letting them off the hook; they will become weak and vulnerable; they won’t be able to ‘push’ themselves into achievements. One person described the beginning of compassion work as ‘weak’ and ‘wet’. When people have negative beliefs about compassion, the therapist always follows the threat fear. - - Reminded me of [[Daring Greatly How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead]] - about the fear that if they talk about emotions, they overwhelmed by negative emotions. ## 12  Focusing Interventions with a Special Reference to Self-Criticism 267 ## 13  Working with Specific Difficulties I: Approval, Achievement, Assertiveness and Rebellion 291 ## 14 Working with Specific Difficulties II: Shame, Guilt, Ideal and Envy 306 ## 15 Overview, Saying Goodbye and Personal Reflections 327