Laura, one of my clients diagnosed with depression, started treatment by saying, “I just don’t feel good enough to do anything.” Laura had decided to start cognitive behavior therapy (CBT) with me after seeing a traditional supportive therapist for about two years without experiencing the improvement she desired. I asked Laura what her previous therapy focused on. She said, “We were trying to figure out why I felt so depressed and come up with ways I could adjust my life to my level of depression.”
Laura’s experience of depression is common. Clients often believe that they need to find ways to improve their mood before being able to be more active or engaged in life. The problem is that this is unlikely to happen. One purpose of emotion is to provide us with information. For instance, anxiety tells us we’re facing a challenge, fear means we’re in danger, and guilt means we’ve acted against our values. Depression can be thought of as a stronger and more consistent sadness that tells us we’ve lost something or are missing something important in our lives. Accordingly, when depressed clients are withdrawn from life, they continue to miss what’s important, and their depression is likely to continue.
We first focused on Laura’s values. I used a worksheet that Dr. Norman Cotterell developed to determine her values. It has three columns:
- Value category;
- Value importance (0-10);
- Why it’s important and what activities make up the value?
The first row lists different categories of values:
- intimacy/romantic relationships;
We went through each category and Laura rated how important each value was to her on a 0-10 scale. Then, we filled in the third column with why each value category is important to her. For categories with values of higher importance (e.g. anything she rated over a 5 on a 10-point scale), we added in a list of activities that could help her fulfill the value. Next, I asked Laura if her current life reflected her values; she said it did not. Laura’s highest value was relationships (her marriage, friendships, and family), but she had been isolating herself because she didn’t “feel like” being social.
I asked Laura what activities she wanted to schedule during the upcoming week so that her life could be more in line with her values. She decided to schedule lunch with a friend who had been trying to do so with her for a while. She also agreed to schedule a “date night” with her husband, which had been a weekly event before her depression became more severe. Lastly, she decided to call her mother one night, as she had been reluctant to return her calls lately. When I asked what might get in the way of her following through with these activities, she said she “might not feel like doing them.”
To address this obstacle, I proposed a behavioral experiment to test Laura’s beliefs about her mood. The first scheduled event was the lunch with her friend. I asked if Laura was willing to rate her mood on a 0-10 scale (with 0 being the worst mood ever and 10 the best mood ever) before, during, and after the lunch. She noted that it might be difficult to get herself to the lunch in the first place, so I asked if she “felt like” coming to all of our sessions. She said, “No.” When I asked how she was able to make it to our sessions, Laura said that she told herself how important CBT was to potentially improve her life. I asked her why it was important for her to see her friend. She mentioned the information we wrote down on the values worksheet— that friendships are important for support, sharing experiences, and connection. Laura wrote this information on a coping card to serve as a reminder of why she was choosing to see her friends, regardless of her mood.
When Laura came back the following week, she reported a slight improvement in her mood. She attributed this improvement to following through with the scheduled social activities. I specifically asked about the behavioral experiment about her mood level, and she reported that her mood before the lunch was a 2/10, during a 5/10, and immediately after a 6/10. I asked what she learned from this, and she said, “Being involved in things that are important to me can actually improve my mood.” I asked Laura to write down this important information and we were then able to use what she had learned from this experience to continue making her life more consistent with her values.
If you would like more insight on this topic, Dr. Robert Hindman is leading a workshop at Beck Institute on CBT for Depression and Suicide from March 9 -11, September 14 -16, and December 7-9. This workshop is designed for health and mental health professionals who want to learn the fundamentals of CBT for depression and suicidality.
CBT for Depression and Suicide
March 9 - 11, September 14 - 16, December 7 - 9