|
Chapter 4 Depression - David G. Weight
Abraham Lincoln, who
struggled with depression throughout much of his life, once wrote, "If what I
feel were equally distributed to the whole human family, there would not be one
cheerful face on earth." Depression takes an inestimable toll on the human
family, and it is the most common complaint brought to the attention of
professional and lay counselors alike. The condition might be thought of as the
"common cold" of emotional problems, since it occurs so broadly, is found with
so many other physical and mental disorders, and is difficult to cure. According
to the National Institute of Mental Health, at least 15 percent of all adults
between the ages of eighteen and seventy-four suffer the destructive effects of
depression sometime. The actual incidence, however, may be much higher,
estimated as high as 30 percent. Estimates of dollar costs for this disorder
have been placed at between 300 and 900 million dollars. As a counselor, friend,
or relative of a depressed person, you should quickly recognize how devastating
this condition can be to the person as well as to his family and friends. And
since suicide is often considered by the depressed person as the solution to his
despair and self-condemnation, this condition may be dangerous enough to require
professional treatment.
Signs of Depression
Everyone has changes in mood from
time to time. Negative moods seldom last for more than a few days, and a person
would rarely seek help from a counselor in such cases. These "normal"
depressions are usually related to stress, disappointment, or even biological
change. In many cases, grieving at the loss of a loved one or an important
relationship will produce short-term depression. Short-term counseling in
adjusting to these mood swings may be helpful, and it may avoid the development
of deeper depression. Our greater concerns, however, are for those whose
depression stays relatively unchanged for longer than a week or two.
According to
Aaron Beck, fn depression has four major facets: emotional, cognitive,
motivational, and physical.
Emotional
The depressed person usually has pronounced feelings of
hopelessness and despair with periods of uncontrolled crying and feelings of
guilt and unworthiness. The person will often describe awakening in the morning
and feeling a kind of gloominess settle around him. He may feel that even the
most basic requirements of life are overwhelming and frightening. Such a person
often feels tension and anxiety and finds it difficult to think and concentrate.
He may also feel a loss of control and be troubled by fear of insanity, disease,
or even death. Perhaps the most characteristic emotional symptom of depression,
however, is the person's loss of interest or pleasure in almost all of his usual
activities and pastimes. Nothing seems worth doing. In fact, the severely
depressed individual may have almost no sense of love, excitement, or
accomplishment.
Most depressed
people feel guilty. They often believe that their behavior is sinful and that
their depressive feelings may be God's punishment. They may believe they have
committed an unpardonable sin or have been abandoned by God. In extreme cases
this feeling may be psychotic. fn The counselor will have to evaluate whether
such guilt is justified while recognizing that guilt is often a symptom of
depression.
Some people do
not experience guilt, but blame their depression on external causes. They may
believe that if the counselor or others would reduce their demands, the
depression would leave.
Cognitive
Some depressed people experience poor
concentration, memory problems, difficulty in carrying on a normal conversation,
and preoccupation with the fear of looking foolish. They have great difficulty
making decisions or being creative. Unfortunately, these reactions feed the
person's feeling of inadequacy and incompetence, which produce greater
difficulty in performance and production, which leads to increased feelings of
incompetence, and so on, dragging the person into a downward cycle of despair.
Motivational
Everything seems difficult to depressed people. Morning seems
to be the worst time of the day, since the effort required to get up and get
going seems so monumental. They are afraid to encounter other people or their
usual work, since they will be reminded of their failure and inadequacy. They
often cut back on social activities and stay home for long periods of time,
sometimes in bed. They have little ambition to take on new projects, and church
or work obligations seem overwhelming.
Physical
During depression, the body often exhibits what are known as
the "clinical signs of depression." These include sleep disturbances,
eating disturbances, decrease in sexual drive, and loss of physical energy.
Sleep
disturbances.
Depressed people may have a difficult time
falling asleep or may awaken early in the morning and not be able to get back to
sleep. However, they may also require more and more sleep, wanting to spend
every available moment in bed.
Eating
disturbances.
Those who are depressed may lose their appetites
and experience rapid weight loss. They may describe eating as something that is
done only because it is necessary, and they may get little pleasure from eating.
On the other hand, they may develop voracious appetites with nervous and
sporadic eating throughout the day. Constipation and gastrointestinal problems
are also typical.
Decrease in
sexual drive.
With a general decrease in the capacity for
pleasure, depressed people often report reduced sexual interest. In severe
cases, the body temporarily loses its capacity for sexual excitement.
Loss of
physical energy.
Depressed people often report fatigue and loss of
energy. In extreme cases, it is difficult for them even to move about the house.
Coordination between the mind and the body may slow to such a point that
reaction time is impaired, and the people may have difficulty with tasks they
usually do well. They may also feel agitated with constant need to pace and to
rub their hands, hair, skin, clothing, or other objects. They usually speak very
little and seem tired even without any physical exertion. They may also report
having pain when there is no medical explanation for it.
Depression in Children
Depression in children can be difficult to recognize. Since
younger children do not have a well-developed ability to think or talk about
abstract concepts, a counselor must look for behavioral clues to a child's
depression. A gloomy mood or failure to find excitement in life are signs of
depression. The child may withdraw from other children, fail to gain weight, or
develop a clinging and insecure attachment to parents or other adults.
Adolescent boys may develop antisocial behavior and feel misunderstood and
rejected. Girls may become sexually promiscuous in an attempt to be accepted by
others. Withdrawal from social activities, reluctance to attend family outings,
and spending increasing amounts of time alone are also signs of depression.
Other signs include difficulty with schoolwork, inattention to personal
appearance, and overly strong reactions to love relationships. The adolescent,
of course, is much more able to think about and discuss depression than can
young children, and they can contribute more to their own treatment.
Medical Causes of Depression
Depression can be caused by medical problems, such as
untreated diabetes, side effects from medications, or changes in the brain from
stroke or senility. Because this is true, if depression lasts longer than a week
or two, the person should see a medical doctor. If the doctor finds no medical
cause for the depression, the person should probably be referred to a mental
health professional.
Counseling the Depressed
Even if the depressed person is seeing a mental health
professional, the lay counselor can do much to help him (being sure, of course,
not to undermine the work of the professional). First, it is important that the
counselor establish a relationship with the person that will inspire confidence.
Depressed people often feel they are disclosing frightening and terrible aspects
of themselves and are afraid that other people would take advantage of this
information and tell it to their neighbors, ward members, and others.
Establishing confidentiality and confidence is vital to helping those who are
depressed.
The counselor
must also attempt to understand the person's despair. Sometimes a counselor
has had depressed feelings and would like to deny the existence of depression in
other people to protect himself from his own feelings. This is particularly true
of one counseling a member of his own family. We love people in our families,
want them to be successful, and want to help them take responsibility for their
emotional problems. However, we may deny the existence or severity of their
depression. Remember, one reason a person seeks out a counselor or confidant is
to find someone who he thinks might understand his feelings. If the counselor
refuses to compassionately understand the person's feelings or dismisses them as
the result of failure to keep the commandments, insufficient faith, working too
hard, and so on, then the counselor may lose his opportunity to help.
The depressed
person needs to know that he is accepted. This can be a challenge for the
counselor, since depressed people are often critical and demanding of themselves
as well as their family, friends, and those trying to help them. As a counselor,
when you recognize this symptom of depression, you will typically avoid the
tendency to feel hurt by the rejection or criticism of the depressed person.
The troubled
person can be helped by learning about the symptoms of depression discussed in
this chapter. In many cases it is helpful to let the person know that he is
experiencing a condition with certain predictable symptoms. This will help
reduce the pressure he tends to put on himself. Many people, especially those
with strong religious commitment, feel that emotional problems are strictly the
result of deficient will or determination. This attitude is a part of their
guilt feelings and actually stands in the way of easing their burdens.
Recognizing that depression has predictable symptoms, the person may be able to
examine some of his unrealistic expectations that may be a part of the
depression.
A cardinal rule
in the treatment of depression is to provide structure in the person's life.
Those who are depressed tend to pull back from the world to avoid being reminded
of their failures and inadequacies. By avoiding or denying their problems, they
actually make them worse. By providing structure, a counselor helps the person
function in the real world and also helps him become distracted from his
obsessive feelings. Structure can be provided in a number of ways. Sensitive
neighbors may be encouraged to develop recreation programs, to share hobbies, to
set luncheon dates, or to provide outings. Part-time or full-time work, as well
as volunteer activity, can provide structure. The counselor might prescribe a
night of the week for the person and his or her spouse to go out together. And
regular walking, jogging, or other exercise programs can be very helpful. It
must be pointed out, however, that structured activity is usually the last thing
the depressed person wants, and consequently he will require considerable
encouragement and direction.
Since the
depressed person feels such despair, it is important that he be offered a sense
of hope from those who are trying to help. The counselor can provide hope by
becoming quite active in the person's life. One of the symptoms of depression is
difficulty in making decisions and seeing the world clearly. Anxiety, which
usually accompanies depression, has a very constricting quality. It produces a
sort of emotional tunnel vision, making it difficult for him to see solutions to
his problems. The anxious person can benefit from someone who can see further
down the road. The kind of support and hope he requires does not come from
patting him on the back, telling him things are not as bad as he thinks, or
helping him count his blessings. The depressed person is likely to respond, "I
have that many blessings and still I'm depressed; I'm a worse person than I
thought—I'm ungrateful!" The support you should give is to help him see that you
understand his feelings and that there are solutions to many of his problems,
but that he is having trouble seeing them. He also needs to know that other
people have felt as he feels and still have been able to survive (and even like
themselves). He can recognize that depression distorts his understanding of
reality—something the counselor can help him straighten out.
Generally,
depressed people should be with others as much as possible. Long periods alone
contribute to withdrawal and self-criticism. Isolated people tend to become
self-centered and do not benefit from the give-and-take of social interaction.
If they are living alone and depression is a serious concern, some attempt could
be made to change their living arrangements so these needs might be met.
An Approach to Counseling
After many years of research, Dr. Aaron T. Beck has developed
a treatment system that is becoming increasingly successful. Some of his
principles can be used by the lay counselor to treat mild to moderate
depressions. Dr. Beck has observed that three major belief patterns are part of
most depressions. The first has to do with the person's negative views of
himself. He believes himself to be inadequate or defective in some way and tends
to attribute his failure and despair to this moral, psychological, or physical
defect. Second, he views his present experience in a negative way. He feels that
the world expects too much of him and that too many obstacles block his
progress. The third belief is a negative view of the future. He is convinced
that his current problems and suffering will continue indefinitely. He expects
frustration and difficulties and is convinced he will fail at any task he tries.
Generally speaking, all of these beliefs give the person the general feeling of
hopelessness that is so typical of depression.
In evaluating the thinking of the depressed person, the counselor will
typically find false assumptions that lead to depression and sadness. Some
of these that have been discussed by Beck fn include the following: (1) to
be happy, I have to be successful at whatever I undertake; (2) to be
happy, I must be accepted by all people at all times; (3) if I make a
mistake, it means that I am a failure; (4) I can't live without my spouse;
(5) if someone disagrees with me, it means he doesn't like me; (6) my
value as a person depends on what others think of me. Some other false
assumptions are these: (1) if I'm spiritual, bad things will not happen to
me; (2) I should be able to make anyone love me; (3) good parents always
love their children and never become angry with them; (4) good people are
never angry and never have negative feelings.
Most depression
is based on such false assumptions. These assumptions lead to false conclusions
and automatic negative thoughts, which lead to catastrophic conclusions. For
example, a person may have this false assumption: If I am a loving person
(suffer for others, do everything that's expected of me, always seem happy and
pleasant), bad things (divorce, financial problems, disobedient children) won't
happen to me. If so, he might conclude, It's my fault when bad things happen
because I'm not loving and good enough. Such a conclusion then leads to
automatic negative thoughts, which Beck says are a major cause of depression.
Examples of such thoughts are (1) I caused my children to disobey; (2) I ruined
my children's lives by getting a divorce; (3) I'm too selfish; (4) I never have
good times; (5) I caused my spouse to have problems. Such thoughts may lead to
such catastrophic conclusions as (1) my spouse will probably divorce me; (2)
people will see what I'm like and fire me from my job; (3) I have disappointed
God, so he will abandon me; (4) if I fail at something as basic as loving, I
might as well be dead; (5) my children will fail and I will be responsible. Not
surprisingly, such conclusions drive the person into despair.
The counselor
can help the depressed person by identifying his false assumptions. However, as
strange as it may seem, such beliefs are often near and dear to the person who
has them. Even though his beliefs are irrational, the person judges his worth on
how well he follows his beliefs. Simply calling the error to his attention will
not be enough. The counselor will need to help him recognize the many times he
thinks these self-defeating thoughts that lead to depression. Helping him do
this must be done carefully and with sensitivity, or he may become defensive and
angry.
The following
list of assumptions and counseling strategies may help you counsel the
depressed. fn
False
assumption:
Failures are important, but successes are not.
Counseling
strategy:
Encourage the person to keep a written record of
his successes and to talk with others to become aware of successes he has
forgotten or overlooked. Being willing to do something about depression is one
success.
False
assumption: I am totally responsible for the
problems of other people.
Counseling
strategy:
Help the person recognize that many of the
problems of others are out of his control. Other people have their own agency
and make their own decisions, and they are ultimately responsible for their own
problems and happiness. Only the Savior himself was able to bear the burdens of
the whole world.
False
assumption:
I am the center of everyone's attention,
especially when I make a mistake.
Counseling
strategy:
Help the person think of times when he really
would be the center of attention and times when he would not. Help him
distinguish between the two. Other people are probably paying less attention to
him than he thinks. For example, few people would notice or even care if his
shirt had a spot on it.
False
assumption:
The worst thing that could happen will happen.
Counseling
strategy:
Help the person understand how slim the chances
are that the worst will always happen. You can do this by helping him remember
that the worst has not usually happened in the past. For example, just because
the person made a mistake at work does not mean he will automatically be fired.
Suicide
Anytime a person is depressed, and particularly if his
feelings are severe, there is a strong possibility he has suicidal thoughts or
intentions. The person will often drop clues about such feelings by making such
comments as "I won't have to worry about Christmas next year," "I just can't
stand it any longer," or "I can't face another day." He may give away prized
possessions or develop unusual concerns about having a will drawn up. When a
counselor knows that a person is depressed, especially if he sees some of the
clues, he should directly question the person about suicidal feelings. Many
depressed people, however, will try to hide these feelings because of the moral
concerns associated with suicide. This should be taken into account, and the
person should be helped to honestly evaluate his feelings. Any person who is
clearly a suicidal risk should be referred immediately for professional help and
possible hospitalization.
Most depressed
people have suicidal thoughts from time to time even though they do not believe
they would ever really commit suicide. However, every statement of suicidal
intent should be taken seriously. One should never assume that the person
doesn't mean what he says. If you are counseling someone with suicidal
thoughts, the following strategies are important: fn (1) Assure your
availability. Let the person know where you can be reached if he is feeling
despondent. (2) Counsel the person much more frequently than usual. You may want
to require him to call you regularly. (3) Contact the person immediately if he
cancels or fails to keep an appointment. (4) Get help from the person's family
and friends, especially those who are sensitive and could help provide
structure. (5) Make sure the person is not left alone for long periods of time.
He may need to stay with a friend or enter the hospital. (6) If the person is
being treated with medication, it is vital that the dosage be carefully
monitored and that some responsible person dispense the medication, particularly
if large quantities are available. (7) Appeal to the person's religious beliefs
and family obligations to reduce the possibility of suicide. (8) Don't give
empty reassurance. Saying something like, "Things aren't that bad; everyone
feels blue once in a while," will likely alienate the person and make him feel
you are not on his side.
Getting Help
Never underestimate the many resources available to help you.
Professional mental health practitioners can be consulted. Churches, families,
and schools have been helping people for years.
Families can be
made aware of the person's symptoms and help him change his interpretation of
his problems. They can become more aware of his needs and become more tolerant
of his problems.
The Church has
many resources, and Relief Society and priesthood leaders can be very helpful.
Professional help is available from LDS Social Services.
Schools often
have counseling programs, and they can also provide opportunities for people to
develop hobbies and skills that promote self-esteem and decreased feelings of
helplessness.
All of these
resources might be used to help the person who is depressed. In addition, you
should use your creativity to come up with other resources that might be helpful
but have not yet been tapped.
Depression: Notes
1. Aaron T. Beck, John A. Rush, Brian F. Shaw, Gary Emery,
Cognitive Therapy of Depression (New York: Guilford Press, 1979.)
2. Psychosis is a severe psychological disorder involving
loss of contact with reality and gross personality distortion. Hospitalization
is ordinarily required.
3. Aaron T. Beck, Cognitive Therapy and the Emotional
Disorders (New York: International Universities Press, 1976), pp. 255-56.
4. Beck, et al., Cognitive Therapy of Depression,
p. 261.
5. See Joan S. Zaro, Roland Barach, Deborah J. Nedelman,
Irwin S. Dreiblatt, A Guide for Beginning Psychotherapists (Cambridge,
England: Cambridge University Press, 1977).
About the Author
Dr. David G. Weight, associate professor of psychology at Brigham Young
University, received his bachelor's and master's degrees from that institution
and his Ph.D. from the University of Washington. A highly respected clinical
psychologist, Dr. Weight has had broad experience in therapeutic work in
Washington and Utah. He is a consultant to Utah Valley Hospital Mental Health
Services and a large Utah school district. He supervises a department of the BYU
Comprehensive Clinic. Professor Weight has written a number of professional
articles.
In the Church, Dr. Weight has served as a missionary, bishop, high councilor,
and a Young Men's president.
He and his wife, Shauna, are the parents of five children.
|
|
