Defeating Depression. Chapters 1 to 8

This guide initially begins by describing depression and its symptoms and then goes on to describe various ways of overcoming depression. You should read the guide from the beginning and follow the instructions given. At the end of the guide there are various forms. These are described in the guide and how and when to use them is also described.

Depression is a very common condition affecting many people. It comes in many forms and varies from a mild transient illness to a more intense and long lasting condition. In fact we often use the term depression for normal sadness. More severe forms of depression are sometimes called clinical depression, endogenous depression or affective disorder.

This guide is suitable for all types of depression but the more severe forms of depression will also need expert help. Therefore you should see your GP who will either prescribe medication or refer you to an expert who will help you in other ways if you have a more persistent form of depression.

The advice in this guide is based upon the principles used in Cognitive Behaviour Therapy (CBT). CBT was originally developed to help depressed patients and has been further developed to help with many psychiatric conditions. In CBT the emphasis is on understanding the way people think. This is because it is thought that the main reason people become depressed is because of maladaptive thinking processes. This in turn leads to depressed feelings and then altered behaviour. Research has shown this type of approach to be a very effective one.

At the end of the guide there is a chapter on drug treatments including a description of some of the more common anti-depressants.

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CIIAPTER 2

WHAT IS DEPRESSION?

As mentioned in the introduction, depression takes many forms. In some respects we have all experienced some of the symptoms of depression as we have all felt sad. However depression is likely to be diagnosed when the symptoms become more severe, widespread and although the change may come gradually, the depressed person is different from the way he was before the onset of his illness - perhaps even the opposite of his usual self. There are many examples of this change: the successful business man who believes he is on the brink of bankruptcy, the devoted mother who wants to abandon her children, the gourmet who cannot stand food, the extrovert who becomes a hermit. Instead of seeking pleasure, the depressed person avoids it. Instead of caring for himself, he neglects himself and his appearance. His instinct to survive may give way to a desire to end his life. His drive to succeed may be replaced by passivity and withdrawal.

The most obvious and typical sign of depression is a sad mood: gloomy, lonely, apathetic. The depressed person may find himself crying even when there seems to be nothing to cry about or may find it impossible to cry when a truly sad event occurs. He may have trouble sleeping or waking early in the morning, unable to return to sleep. On the other hand, feeling constantly tired, he may sleep more than usual. He may lose his appetite and lose weight, or eat more than he does normally and gain weight.

Typically, the depressed person also sees himself in a very negative way. He may believe that he is helpless and alone in the world and often blames himself for trivial faults or shortcomings. He is pessimistic about himself, about the world and about his future. He loses interest in what is going on around him and does not get satisfaction out of activities he used to enjoy. Often, he has trouble making decisions or getting himself to carry out decisions he has made.

Some people may be depressed without showing the usual sad, moody, dejected feeling. They may complain instead of physical discomfort or suffer from alcoholism or drug addiction. When a person always seems tired or bored with what he is doing, he may actually be depressed. When bright children do poorly in school over a period of time, this too may point to depression. There is even evidence that the overly active child may be compensating for an underlying depression.

It is very common for depressed people to believe that they have lost something very important to them, although often this is not really the case. The depressed person believes he is a "loser" and will always be a loser, that he must be worthless and bad and perhaps not fit to live. He may even attempt suicide.

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CHAPTER 3

WHAT CAUSES DEPRESSION?

There are lots of ideas about the origins of depression and no doubt some factors are more important in some people than others.

FAULTY THINKING

This guide is based upon this. Most depressions have this as a factor. It may not always explain how the depression started but is often responsible for its persistence. There are many thinking errors and patterns that can lead to depression and these will be described later in detail. Cognitive therapists talk about the negative cognitive triad i.e. negative thoughts about yourself, your life and your future. These thinking errors lead you to misinterpret things in a negative way leading to depression. Depression in itself leads to more negative thoughts producing a downward spiral.

BIOLOGICAL FACTORS

In some people chemical change in the nervous system leads to recurrent episodes of depression. These may be inherited, however even if it runs in your family the chance of any close relative getting it is only 1 in 10.

This is sometimes accompanied by swings in the mood in the opposite direction and this is called manic depressive illness or bipolar affective disorder. This guide may help with these types of depression but medication will also be needed in nearly all cases. Therefore you should consult your doctor.

SEASONAL AFFECTIVE DISORDER (SAD).

SAD occurs in late Autumn/early Winter but not at other times. It occurs most years. It is due to the shorter length of daylight in the Winter and responds usually to a special type of light treatment.

POSTNATAL DEPRESSION

This is probably due to the changes in the hormonal systems that occur around the time of delivery. When severe, this needs expert medical help as medical treatment including drug treatment will often be required. It usually occurs shortly after child birth but can come on several months later.

EXTERNAL EVENTS

To some extent this is the most obvious cause to most people i.e. something bad happens leading to depression. Whilst this is sometimes true and can explain a persons depression, often nothing of note appears to have happened. Even when an adverse event has happened other events of equal severity have occurred in the past but not led to depression. It is often the meaning of external events rather than the events themselves that is important i.e. the thoughts or cognitions.

Although the above causes are listed separately it is common to have a combination of different factors leading to depression. Therefore do not be surprised if you find that this is so for you. In fact it is often the combination of two or more things that triggers many depressions.

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CHAPTER 4

AN OVERVIEW OF HOW TO DEFEAT DEPRESSION

This guide will present a series of things that will help you overcome depression. Firstly it will look at the effects of inactivity and then suggest ways of overcoming it. Next it will look at the thinking process that occurs in depression and will teach you how to overcome these. It will also explain how you can test out your thoughts. Finally it will also explain about longer term beliefs that may make you vulnerable to depression.

Although the ideas in this guide are fairly simple to understand they may be difficult to put into practice. Like anything that is new to you, you will get better with practice. Therefore it is important that you use the suggestions given regularly so even if you cannot do it at first, keep trying. Also the guide is laid out in the order that you will need to do things therefore you should not move on from one section to the next until you have made some progress on the previous chapter. You will find as you go on that it will get easier but nevertheless you will probably have setbacks. Do not be discouraged as setbacks can help strengthen the skills you have learnt.

As mentioned in the introduction this guide is based on the principles of cognitive behaviour therapy. Cognitive is another word for thinking, therefore the advice given will focus on thoughts and behaviours (or actions). This does not mean that emotions are ignored. However you know how impossible it is to respond to suggestions to "cheer up", "be happy^"etc. However you will probably find the advice in the guide easier to act on.

There is no magic wand and the advice in this guide requires you to put in a lot of effort. However this will prove worthwhile. It also takes time. Do not expect to read through the rest of this guide and be instantly cured. Acting on the advice given takes time - several weeks. During this time you will continue to have problems with depression but it will gradually get better. You may find some of the suggestions difficult at first but keep persisting and you will probably succeed in the end. At the end you will have a set of skills and ideas to deal with any future tendency to depression.

If you are on medication you should continue with this as the advice in this guide can be used to help the effects of medication and visa versa.

If you have managed to get this far you have already made a start on overcoming your depression, so good luck and move on to the next chapter.

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CHAPTER 5

HOW TO ACTIVATE YOURSELF

THE PROBLEM

Depression is a vicious circle. It slows you down, mentally and physically. It makes everything an effort. You tire easily. You do less, and blame yourself for doing less. You come to believe you can do nothing, and that you will never get over it. That makes you more depressed. It becomes even more difficult to do anything. And so it goes on.

THE WAY OUT

Becoming more active is a way to break the vicious circle:-

Activity makes you feel better. If nothing else, it takes your mind off your painful feelings. It gives you the sense that you are taking control of your life again, and achieving something worthwhile. You may even find there are things you enjoy, once you try them.

Activity makes you feel less tired. Normally when you are tired, you need rest. When you are depressed, the opposite is true, - you need to do more. Doing nothing will only make you feel more lethargic and exhausted.

Activity motivates you to do more. In depression, motivation works backwards. The more you do, the more you feel like doing.

Activity improves your ability to think. Once you get started, problems which appeared insoluble come into perspective.

People who matter to you will probably be pleased to see you doing more.

THE DIFFICULTY

In spite of these advantages, getting going again is not easy. This is because the negative thoughts which are typical of depression, stand in your way. When faced with something you want to accomplish you find yourself thinking "I won't enjoy it", "I'll only make a mess of it", "It's too difficult", etc. These thoughts will block you from taking action.

Later on, you will work directly on the thoughts which are stopping you from getting down to what you want to do, no matter how you try. Your aim will be for you to learn to notice and challenge them so that they no longer stand in your way. But first of all your goal is to find out exactly what you are doing and then to build on what you discover.

ACTIVITY SCHEDULES

Many depressed people firmly believe that they are doing nothing, achieving nothing and enjoying nothing. They find it difficult to organise their time productively, or to involve themselves in things they normally enjoy.

An Activity Schedule is an hour-by-hour record of what you do. It is a means of showing you how you are in fact spending your time, and of helping you to plan your day enjoyably and productively. There are two steps involved:

STEP 1. SELF-MONITORING

1. For the next few days record exactly what you do hour-by-hour. At the end of this guide there are two forms that you can use for this (Appendix 1 and 2 - daily and weekly Activity Timetables)

2. Giving each activity a rating between 0 and 10 for Pleasure (P), or sense of achievement (A). P 10 would mean that it had been extremely enjoyable. You can use any number between 0 and 10 to indicate the degree of enjoyment or pleasure you experienced. Similarly, A O means no sense of achievement, and A 10 a considerable sense of achievement. Again, you can use any number between 0 and 10 to indicate the degree of achievement you experienced.

3. It is important to rate your activities for P and A at the time, not in retrospect. If you wait until later, your depression may cause you to devalue and discount what you have done. When people are depressed negative and unpleasant events are more easily noticed and remembered. The good things are blotted out by a sort of global pessimism. Immediate ratings will help you to become sensitive to even small degrees of pleasure and achievement which might otherwise go unnoticed.

4. Achievement should be rated according to how difficult the particular activity is for you now, not for how difficult it was for you before you got depressed or how difficult everyone else would find it. when you are depressed things which would normally be very easy become difficult, so give yourself credit when you achieve them. This is a very important point. Your natural tendency will be to devalue your achievement because it is lower than what you would normally do. However you will have probably had to put in a lot of effort and it is this that you should be rating. Do not compare yourself to your healthy state or others or you will just end up criticising yourself.

Your Activity Schedule will give you hard data on what you are, in fact doing and enjoying, and so challenge the belief that nothing goes well for you. You are quite likely to find that you are more active and competent than you assumed and that you are enjoying yourself more than you thought.

Even if not, you will have valuable evidence to hand to help you find out what is getting in your way.

Here is an example of an Activity Timetable completed for a few hours:-

TIME

ACTIVITY

0-10

8 - 9

9 - 10

10 - 11

11 - 12

Lay in bed

Got up, washed,dressed and had a cup of tea.

Friend visited.

Did some ironing.

7**

* Note - even when depressed you can still get some pleasure.

** A = 7 because it took the person a lot of effort to motivate herself

STEP 2. PLANNING AHEAD

Now that you know how you are spending your time, the next step is to plan each day in advance including the sort of activities which give you sense of enjoyment and achievement.

Each evening take a few minutes to plan for the next day. Pick a time when you think you will not be busy, tired or distracted. Make a note of what you plan to do the next day hour by hour. If you find it difficult to plan out the whole day just plan the morning. Then balance your activities between easy and enjoyable things and more challenging but not too difficult things. Keep the plan simple at the beginning and slowly build up to more difficult and challenging things. There is no rush - remember Rome wasn't built in a day. There are three reasons for keeping to a plan of activity.

1. Structuring your time will allow you to feel that you are taking control of your life again and give you a sense of purpose.

2. The framework you give yourself will prevent you from sinking in a swamp of minor decisions and help you to keep going even when you are feeling sad.

3. Once the day's activities are laid out in writing they will seem less overwhelming. You will have broken the day down into a series of manageable units rather than a long shapeless stretch of time which you must somehow fill.

HOW TO MAKE YOUR ACTIVITY TIMETABLE A HELP RATHER THAN A HINDRANCE

1. Be flexible. Your schedule is a guide, not a god. Something unexpected may happen (a friend comes to visit you without warning for instance) to throw you off schedule. This is a point where you might become discouraged and be tempted to give up. Don't - just continue with your plan when you can.

2. Think of alternatives.Some of the activities you plan may depend on factors beyond your control, (e.g. the weather, the washing-machine breaking down). Supposing, for instance, you have planned a picnic, have something up your sleeve in case it rains.

3. Stick to the general plan. If for some reason you are unable to do what you have planned at the time you planned it you wanted to clean the bedroom and ended up talking to your son about his holiday plans), don't go back and try to do it later. Move on to the next activity, and plan what you have missed for the next day. If you finish an activity sooner than planned, leave your next activity until it is time for it on the Timetable and fill in the gap with a pleasurable activity e.g.. have a cup of tea, read the newspaper, watch TV or phone someone.

4. Plan your activities by the hour or half hour. Don't be specific, or too general. Cleaning the house is too general. Listing every piece of furniture you have to dust is too specific. Find the happy medium e.g. vacuum the living room. Experience will tell you how long each activity is likely to take.

5. Plan for quantity, not quality. Write down the amount of time you are going to spend on a particular activity, not how much you are going to do in that time. How much you can do may depend on factors outside your control (interruptions, mechanical failures) or on other problems (difficulty in concentrating, fatigue). If you tell yourself you must weed the entire garden and you don't do it, you'll probably think of yourself as a failure and get discouraged. If you simply plan to weed for an hour, then how much you do is neither here nor there. Remember, if a thing's worth doing, it's worth doing badly, i.e.. doing it partially or to a lower standard than normal is better than nothing at all.

6. Stick to the task in hand. Your immediate goal is to stick to the Timetable, not to get over depression. If you work steadily at becoming more active you will eventually feel better. But don't expect to be over the depression after an hour's television or mowing the lawn. If you do, you will only disappoint yourself.

7. At the end of each planned day, review how you have done. This will help you to see clearly what you are doing, what room there is for improvement and what changes you might like to make in the pattern of your day. If you did not manage to stick to your plan you may well learn something valuable about why you have been finding it difficult to become more active. Ask yourself what the problem was and what you might do about it in future. Did you overestimate what you could do in an hour? Did you feel tired? Did you plan too many achievement activities and not enough pleasure and relaxation? You can learn from these experiences.

8. Remember that you are always doing something. Sitting in a chair reading the paper is an activity. So are going to bed, staring out of the window brooding. But they may not be the activities which will give you the most satisfaction.

PRACTICAL TASKS

Depression often leads people to put off practical tasks they need to carry out. The pile mounts, and they end up feeling completely overwhelmed. Where to start?

You can help yourself get started on the things you need to do by following these steps:

1. Make a list of everything you have been putting off.

2. Number the tasks in order of priority - which needs to be done first? If you can't decide, number them in alphabetical order. The important thing at this stage is to do something.

3. Take the first task and break it down into small steps. What exactly do you have to do in order to complete it? e.g.. washing the car involves finding car shampoo, bucket etc. Filling bucket with hot water, washing the car, rinsing the car and putting things away.

4. Rehearse the task mentally, step by step. Write down any practical difficulties you may encounter, and work out what you will do about them, e.g.. no car shampoo, go to garage to buy some.

5. Write down any negative thoughts that come to you about doing the task, and answer them. If you cannot do this at this stage do not worry. Later on you will find some instructions to help you with this, e.g.. it is too far to go to the garage - answer, ask someone to get some for you, catch a bus, borrow some from neighbour etc.

6. Take the task step by step, dealing with difficulties and negative thoughts as they occur, just as you have practised mentally.

7. Quit when you are winning, not when things are going badly. This will leave you feeling good about what you have achieved and ready to carry on. So if things are not working out, do not stop, try a little harder and hopefully things will get better -that's the time to stop.

8. As soon as you have finished, write down what you have done on your Activity Schedule, and rate it at once for P and A.

9. Focus on what you have achieved, not on all the other things you still have to do. Watch out for negative thoughts which will make you devalue or discount what you have done.

10. Take the next task and tackle it in the same way.

THOUGHT-BLOCKS TO BECOMING MORE ACTIVE

When people are depressed over long periods of time, it is their negative thinking that keeps them so. Most people get over depression within a certain period. If they don't, there is sure to be some negative thinking going on, keeping them depressed. The most powerful way to overcome your depression is to identify your negative thoughts as they occur, and to challenge them. Here are some examples of the kind of thoughts that may be preventing you from becoming more active, together with some possible answers to them. These are not the right answers, or the only answers - they are just some suggestions. With practice, you will be able to find the answers that make sense to you.

Automatic negative thoughts	Possible answers
I can't do anything - there are too many practical difficulties.	There are always practical difficulties involved in doing anything - it's part of life. What would I do if I wasn't depressed? Is there anyone who could give me advice with those I don't know how to handle (e.g.. lawyer, doctor)?
I can't keep a Timetable - I've never been a record-keeper	Keeping written records is a skill that I can learn. I may not have done this before, but that does not mean to say I can't if I try. After all, I've used lists before, for shopping and to remember what to take on holiday. I could start by listing all the things I have to do.
There's too much to do - I can't cope.	Believing that is all part of the depression. If I write down what I need to do, it won't seem so overwhelming. I don't have to do it all at once. I can take things one at a time.
It's too difficult I don't want to.	It only seems difficult because I'm depressed. I've done more difficult things than this in the past.
I don't want to.	I don't now but I did earlier on. In any case whether I want to now is irrelevant. The point is, it would be better for me to do it.
I don't think I'm up to it just now- I'll wait till I'm feeling better.	I won't know if I'm up to it until I try. If I wait until I feel like it, I'll never do it.
I've already wasted far too much time. There's no point, it'll just make me think of all the time I've wasted. I should have done it last week.	I haven't wasted time. I've just done something else with it. The point is, what am I going to do now, more of the same, or something different?
I can't decide which thing to do first.	Do whatever comes first in alphabetical order. The important thing at this stage is to do something. Once I get moving, I'll probably have a clearer idea of what to do next.
There's no point in trying - I'll only make a mess of it, and then I'll feel worse.	I don't know that till I try. Nobody's asking for a 5 star performance. Even if I do make a mess of it, that's not the end of the world, I can learn from my mistakes.
I won't enjoy it.	How do I know? Since when was I a fortune teller? Try it and see.
I won't be able to do everything I've planned.	No-one ever does all they've planned so I won't feel badly about it. Think about what I have done, not what I haven't.
I'm not doing anything.	Write down what I do, and see. Maybe I just think I'm not doing anything.
But I don't do anything worthwhile.	No-one's asking me to evaluate what I'm doing. Just to do it. If I devalue what I've done, I'll get discouraged.
I don't deserve to enjoy myself.	It will help me to feel better. That's good in itself. It could also help me to do other things more efficiently. Everyone deserves to enjoy themselves sometimes.
So I cleaned the car. So what?	Normally that wouldn't be difficult at all. But right now it's extremely difficult. In spite of that, I did it. I can give myself credit for that A is 10.

TEN HINTS TO HELP YOU STICK TO THE PLAN

1. Set aside some time each evening to note what you have achieved and what you plan to do the next day.

2. If you find something difficult, talk to yourself and give yourself instructions and encouragement e.g.. if you plan to write a letter, say to yourself - "go to the drawer and get a pen and paper" ."Write your address and the name of the person the letter is to etc." .Praise yourself at each stage e.g.. "that's good", "well done".

3. Watch out for unhelpful thoughts - try not to listen to them instead write them down to be answered later if necessary.

4. Remove any distractions to help you concentrate e.g.. turn of the TV etc.

5. Avoid going to bed during the day. If you need to relax during the day, sit in a comfortable chair, have a bath or listen to music or anything else that helps you relax.

6. Give yourself little rewards as you go along - a cup of tea, a short rest etc. You deserve a treat if you have worked hard.

7. Arrange reminders for yourself e.g. notes, tell friends and family to help you keep to your plan.

8. Plan something that you can easily achieve to start the day. This will get you off to a good start.

9. Balance the things you need to do with the things you want to do.

10. Think of things that have been rewarding and pleasurable in the past before you were depressed - these are likely to be rewarding again.

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CHAPTER 6

NEGATIVE AUTOMATIC THOUGHTS

You will already be aware from what you have already read of the importance of the way you think. When you are depressed your thinking becomes very biased and negative. These negative thoughts appear spontaneously and frequently. We call these depressing thoughts Negative Automatic Thoughts (NAT) for obvious reasons. These thoughts are usually focused on one of three areas.

a) Yourself - e.g.. I'm a loser. I'm useless.

b) Your world - e.g.. No-one cares about me. My job is lousy.

c) Your future - e.g.. It will always be this way. I'll never find any friends.

Negative Automatic Thoughts have the following characteristics:-

1) They are automatic - they pop up in your mind without any effort.

2) They are unhelpful - they maintain the depression and make it hard to change.

3) They are believable - so much so that you don't think to question them.

4) They are persistent - they can be very hard to switch off, it takes effort.

Because Negative Automatic Thoughts cause depression and depression leads to more Negative Automatic Thoughts, a downward spiral begins and the depression becomes self maintaining leading to despair and helplessness. This is why it is important to learn how to overcome these Negative Automatic Thoughts. However before you can do this you have to understand a little more about the way you think.

Whenever something happens we try to make sense of it i.e.. to explain why it happened, what it means and how to and whether to respond. We do this by comparing what has just happened with previous events of a similar nature. Because so many things have happened to us we have to develop some rules about the way the world works. Many of these rules are shared by everyone e.g.. hot things burn you and cause you pain. These rules are in the main helpful. However people also have more private rules and these are not the same for each of us. These rules for living or beliefs are also usually helpful but sometimes they become unhelpful or dysfunctional. People who have dysfunctional beliefs are more likely to become depressed. These beliefs can often lie inactive for many years waiting to be triggered. This will be described in more detail later in the guide. When these dysfunctional beliefs are activated, Negative Automatic Thought becomes more prominent and frequent and this causes depression and the downward spiral mentioned earlier.

In order to overcome depression it is necessary to deal with the Negative Automatic Thoughts. In order to help build up your resistance to further episodes of depression it is necessary to work on the dysfunctional beliefs. However this cannot be done easily until the Negative Automatic Thoughts are under control. Also by recognising the recurrent themes in the Negative Automatic Thoughts you will be able to learn more about your dysfunctional beliefs.

There are 10 thinking errors that are common in Negative Automatic Thoughts and depressed people. Although non depressed people may also have the thinking errors they are not as extreme or as frequent. Read through the list below and see which apply to you. You may not use all of them but you are sure to recognise some.

1. All or nothing thinking. Everything is seen in black and white terms with no shades of grey e.g.. if you don^'t do something perfectly you see yourself as a total failure.

2. Over generalisation. i.e.. One bad thing is seen as a pointer to all things. e.g.. You often use "always" and "never". You make a mistake and say "I never get it right" etc.

3. Mental filter. You let your mind focus on only the negative things and Ignore the positive ones thus life seems to be a series of depressing events.

4. Disqualifying the positive. This is similar to the mental filter above but in this you notice a positive event but then undermine it by saying such as "anyone can do that" or "It was a lucky guess" .This allows you to maintain your negative beliefs even though there is evidence to contradict it.

5. Jumping to conclusions. In this you make an assumption with no evidence to support it e.g.. someone may not notice you in the street and you assume they have fallen out with you or are angry with you without checking this out or you may predict a negative outcome for something you plan to do even through you have no evidence for this.

6. Magnification or minimisation. i.e. Making mountains out of mole hills or reducing the importance of positive information e.g.. because you are late your friend will be angry and never want to see you again or someone says you are really interesting and a good friend and you say that they say that about everyone or are only saying it to make you feel better.

7. Emotional Reasoning. I feel it therefore it must be true, you let your heart rule your head e.g.. because I feel guilty I must have done something wrong.

8. Shoulds, oughts and musts. When you tell yourself you should, ought or must do something and then fail or cannot do what you set out to do, you criticise yourself. You leave yourself no room for manoeuvre nor allow for external factors interfering. If you direct the shoulds, oughts and musts at others you get frustrated and angry when they don't come up with the goods or use it as an example of your own undesirability.

9. Labelling and mislabelling. This is an extreme form of over generalisation. You give yourself a label associated with the negative behaviour e.g.. if you make a mistake, you describe yourself as hopeless. It is the event that goes wrong but you label yourself not the event.

10. Personalisation. You assume responsibility for everything that goes wrong even when there is no evidence for it e.g.. if the washing machine breaks you blame yourself for mistreating it even though there is no evidence for this. You blame yourself but in reality blame is only reasonable if you intend something, otherwise it is unfortunate and regretful.

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CHAPTER 7

QUICK CONTROL OF NEGATIVE THOUGHTS AND FEELINGS

In this section you will learn some ways of quickly reducing the intensity of negative emotions and thoughts. They should only be used in the early stages of overcoming your depression or when you feel overwhelmed by your feelings. They will give you a sense of control but they will not provide a long term solution to your problems. However at the beginning you need some success quickly even if this is only temporary. There is nothing like success to make you feel better. Later on you will learn ways of challenging your thoughts and defeating them. The aim here is to help you to escape them. Remember you are learning new skills therefore do not expect immediate success. Try out different ones and use the ones most suited to you. You should try to use them whenever you feel bad. You may find that one will work on one occasion but not another; if this happens try another one until one works. Because you are depressed you are likely to predict failure and therefore not try (remember jumping to conclusions from the previous chapter). initially these techniques may only work for a few minutes but with practice they will be effective for longer periods and may eventually become second nature.

1. TECHNIQUES

a) Focus on an object

When you notice yourself feeling bad, choose an object in your surroundings and describe it to yourself in as much detail as you can. Anything will do - a chair, a house, a tree, a light switch.

Ask yourself questions about it. what is it? What colour is it? What shape? Has it any flaws? How would you improve it? The more intensively you involve yourself in it, the better you are likely to feel.

b) Sensory awareness

Make yourself aware of your surroundings as a whole. Use as many senses as you can, as intensely as you can. What can you see? Hear? Feel? Smell? Taste? The more senses you use, the more effective the strategy will be. Try to immerse yourself in every detail, no matter how trivial.

c) Visualising pleasant scenes

Use memories of pleasurable experiences you have had, to distract yourself. Again, make the memories as vivid and detailed as you can. where were you? who with? what could you see? Hear? How did you feel? etc.

d) Fantasies

Use your imagination to fantasise about things you would like to happen. what exactly would you do for instance, if you won £1 million? Or if you had the opportunity to travel the world, where would you go? what would you like to do and see? who would you go with? Or try to imagine a time in the future when you will no longer be sad.

e) Mental exercise

These can be a useful way of distracting yourself from painful thoughts. For instance:-

- counting backwards from 100 in 7s (when you finish, start again at 105, then 110 and son on)

- recalling what you heard on the news

- recalling what you would see on a journey or a walk familiar to you

- remembering poetry or songs you have learned in the past

f) Running commentary

Describe to yourself in detail what you are doing. This can be helpful, for instance, if you get tense while driving, give yourself a running commentary on what you are doing. "Now I'm changing up. I put my left foot on the clutch and press down, I move the gear lever. There is a car in front of me, its registration number is ... .I^'m keeping at a distance of x yards from it.

2. LIMITING THE EXPRESSION OF SADNESS

Sometimes talking to someone about your problems can be a great help. But it may only make you more painfully conscious of your feelings, and strain relationships with family and friends, who feel unable to be of real help to you.

Try to limit the amount of time you spend talking to others about how bad you feel:

a) Avoid emotional "temperature-taking ". Don't introduce the subject yourself, and if asked how you feel, reply briefly and immediately change the subject ("and how about you?")

b) Make a point of talking about positive or neutral events and experiences.

c) Focus your attention on the other person. Think of questions to ask them, and make yourself concentrate on, and respond to their replies.

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CHAPTER 8

CHALLENGING NEGATIVE THOUGHTS

You have read in this guide how depressed people typically think in a biased, negative way. They have a negative view of themselves (I'm no good), the world ("Life has no meaning") and the future ("It will always be this way").

Negative thoughts have several characteristics:

1. They are automatic - they just 'pop up' without effort on your part;

2. They are distorted - they do not fit the facts;

3. They are unhelpful - they keep you depressed and make it difficult to change;

4. They are plausible - it does not occur to you to question them;

5. They are involuntary - they can be very difficult to switch off.

The more depressed you are, the more negative thoughts you will have, the more you believe them - and the more depressed they make you.

The time has now come to make negative thinking our main focus. This is the heart of the cognitive therapy - learning to recognise when you are thinking negatively, to look for more positive and realistic ways of viewing your experiences, and to test these out in action.

At first, you may not find it easy to "catch" and answer your thoughts, but with regular practice it will come more naturally to you. Answering negative thoughts is like any other skill - it takes time to be able to do it with ease so don't be discouraged if you have difficulties to start with, keep practising and you will become more skilled at it.

1. COUNTING THOUGHTS

Counting negative thoughts is one way to make yourself more aware of what you are thinking, while lessening the power of the thoughts to distress you. It allows you to stand back from the thoughts, and simply observe them as they occur - rather like standing by the side of the road taking a traffic census rather than standing in the middle of the road getting run over by every car that passes.

You can tot up your negative thoughts on a knitting or shopping counter, or by carrying a small card and making a mark on it for each thought that occurs. At the end of the day, see how many thoughts you had. You will probably find that the more you had, the worse you felt during the day. Don't be alarmed if you seem to be having more negative thoughts than ever. It may simply be that you are getting better at catching them. In the long run you will probably find that they become less frequent. And don't blame yourself for having so many. This is a sign of depression, not of weakness or inadequacy.

2. BECOMING AWARE OF THE CONTENT OF YOUR THOUGHTS

The first step in overcoming the negative bias is to become aware of what you are thinking, and its effect on you.

Negative thoughts make you feel bad - anxious, sad, depressed, hopeless, angry. Instead of being overwhelmed by these feelings, you can learn to use them as a cue for action. Notice when your mood changes for the worse, and look back to what was running through your mind immediately beforehand.

Over the course of a few days, you will become sensitive to changes in your feelings, and to the thoughts which spark them off. You may well find that the same thoughts occur again and again.

The best way to become aware of negative thoughts is to write them down as soon a they occur. Use the Daily Record of Negative Automatic Thoughts, at the back of this guide (Appendix 3). Print off some copies to use yourself . Look at one of the forms and you will see a number of columns. In the appropriate column record-

a) The Date

b) What Situation you were in when you started to feel bad. What were you doing? This includes what, in general terms, you were thinking about - worries, memories and ruminations. Only put down the general subject here. What precisely was going through your mind, should go in the next column.

c) What Emotion(s) you felt, and how bad it was; scored out of 100. 0 would mean no emotion, and 100 extremely strong emotion. You could score anywhere between 0 and 100 - 50 would be a moderate degree of emotion, and so on.

d) What Automatic Thoughts were running through your mind at the time you started to feel bad? Try to record these as precisely as possible - write them down word for word if you can. Some of your thoughts may take the form of images, rather than words. You might, for instance, imagine yourself being unable to cope with a situation in the future. Write down what you saw in your mind's eye.

There may be occasions when you cannot identify any thoughts as such. In this case, ask yourself what the meaning of the situation is. What does it tell you about yourself, your situation, or the future. This may provide you with a clue as to why the situation is depressing, or makes you anxious. An argument, for instance, might mean to you that you never manage to get on well with anybody, and will never have proper relationships. If you find yourself having conflicting thoughts i.e. a rational one and a 'gut feeling' write the gut feeling down. The rational one comes later.

e) How far do you believe each of your automatic thoughts? 100% means you believe them completely, 0% that you do not believe them at all. You could score anywhere between 0 and 100..

It may not be possible, for external reasons, to record your thoughts and feeling immediately they occur. If this is the case, make a mental note of events and experiences which distress you during the day, and set aside a brief period (say 30 minutes) in the evening to make a written record. Run through an 'action' replay, trying to recall in as much detail as possible what happened, how you felt, and what your thoughts were.

Beware of excuses which keep you from focusing on your thoughts and emotions. You may say to yourself, for instance, "I'll do it later", or "I'd do better to forget all about this". You may find that you feel very unwilling to look your thoughts in the face. It is quite natural to want to avoid thinking through unpleasant experiences, but doing so is the best way to combat your depression. If you find yourself making excuses, this is probably because you have hit on something important, so make yourself write it down. You can then divert your attention to engaging in a distraction exercise from Chapter 7 if you want to. But ignoring the thoughts won't make them go away, it only gives temporary relief. However at this stage it is important to become aware of your Negative Automatic Thoughts. You will soon learn how to answer the Negative Automatic Thoughts.

3. ANSWERING NEGATIVE THOUGHTS - THE RECORD SHEET

It is extremely important to record and answer as many thoughts as possible each day. Writing them down allows you to become more objective about them. In the end, you will probably be able to answer them in your head as they occur. But if you try to do this initially, the thoughts will be too strong for your answers and will wipe them out. Writing the answers down gives them power - there they are, in black and white. You may need to work out answers to 50 or 100 thoughts on paper before you can do it in your head with ease - if then. This does not mean that finding effective answers will not become easier with practice.

Use the daily Record of Negative Automatic Thoughts to record your answers as follows:

a) Rational Response - write down all the answers you can think of to each thought, and give each answer a rating for belief out of 100. 0% means you don't believe the answer at all. 100% means you believe it completely. You could score anywhere between.

b) Outcome

1. Go back to the original negative automatic thought. Now that you have answered it, how far do you believe it out of 100? You should find that your belief has decreased to some extent. If it hasn^'t, it may be that you are disqualifying the answer in some way - telling yourself that it is just a rationalisation, or that it may apply to other people, but not to you. If so, write down the disqualifying thought and answer it in the same way. Don't expect your belief in the negative thoughts to disappear completely in one go. They have probably been around for a long time, whereas the answers may be quite new to you. It will take time and practice to build up belief in them, and you will probably need to test them out in action.

2. Look back at the emotion column and check how you felt before answering negative thoughts. What are your emotions now, in the light of the answers? Rate each one out of 100.

c) Ask yourself what action you can take. Either to change the situation for the better, or to test out the answers to your negative thoughts. How Would you like to handle the situation next time it occurs? What will you do if you find yourself thinking and feeling the same way again? Try to work out a strategy you can use in the future, should you find yourself facing the same difficulty.

HOW TO ANSWER NEGATIVE THOUGHTS

Once you have learned to become aware of negative thinking, the next step is to evaluate the-thoughts you identify, and look for more helpful and realistic alternatives.

HOW TO DO IT

There are four major ways of questioning and altering negative thoughts:

a) What is the evidence? Do the facts of the situation back up what you think, or do they contradict it?

b) What alternative views are there? There are many different ways to look at any experience. How else could you interpret what has happened? Get as many alternatives as you can, and review the evidence for and against them. When you consider it objectively, which alternative is most likely to be correct?

c) What is the effect of thinking the way you do? How does it influence how you feel and what you do? what advantages and disadvantages of thinking this way? Can you find an alternative which will have a more positive effect?

d) What thinking errors are you making? Depressed people typically distort their experience in systematic ways. They jump to conclusions, over generalise from specific experiences, take responsibility for what is not their fault, and so on. which of these errors can you find in your own thinking? (See Chapter 6, )

Further on in this Chapter you will find questions designed to help you challenge your negative thoughts, together with examples.

WARNINGS

a) Standing back, questioning, evaluating and answering our thoughts is not something we normally do. You may find it difficult at first to be objective, and to find answers which affect your feelings to any great extent, so give yourself a chance to get the hang of it, and don't be discouraged if at first you can't always find effective answers. Would you expect to win Wimbledon after 6 tennis lessons?

b) It will be particularly difficult to find rational alternatives when you are feeling badly upset. You may find it helpful in this case simply to write down what is distressing you, to distract yourself until you are feeling calmer, and then to return to what you have recorded and look for answers. You will be in a better position then to do so. Beware of making the situation worse by telling yourself that you are a failure, or that this won't work for you.

c) Your record does not have to be a literary masterpiece. Nor do you have to find the one right answer. A good answer is one which succeeds in changing the way you feel and how far you believe your automatic thoughts, and which opens up avenues for action. No one answer will do for everybody. You have to find the ones which work for you.

d) Watch out for self - criticism when you are recording your thoughts. You may find yourself thinking "I must be really stupid to think this way". Remember that negative thinking is a sign of depression, which you can overcome, not of lack of intelligence.

e) Don't be discouraged if you find the same thoughts occurring again and again. If you have been depressed for some time, thinking negatively will have become a well-established habit which will take time to break. The more often a particular thought occurs, the more opportunity you have to answer and change it.

QUESTIONS TO HELP YOU CHALLENGE NEGATIVE THOUGHTS

Below are twenty questions you can ask yourself concerning your Negative Automatic Thoughts. Along with each question is an example of a Negative Automatic Thought and a possible way of answering it. They are grouped into the four main ways of challenging Negative Automatic Thoughts:-

WHAT IS THE EVIDENCE?

1. Am I confusing a thought with a fact? The fact that you believe something to be true, does not necessarily mean that it is. Would your thought be accepted as correct by other people? Would it stand up in court, or be dismissed as circumstantial? What objective evidence do you have to back it up, and to contradict it?

Automatic thought	Possible answer
When I met Peter in the street today, he didn't smile at me. I must have done something to to offend him.	It's true that he didn^'t smile at me but I have no reason believe he's offended with me. It probably had nothing at all to do with me - maybe he just had something on his mind.

2. Am I jumping to conclusions? This is a result of basing what you think on poor evidence. For instance, depressed people often believe that others are thinking critically about them. But none of us are mind-readers. How do you know what someone else is thinking? You may be right, but don't jump to conclusions - stick to what you know, and if you don't know, see if you can find out.

Automatic thought	Possible answer
My husband didn't eat that chocolate cake I baked for him. He thinks I'm a terrible cook.	All I know for sure is that he didn't eat it. I don't actually know whether he thinks I'm a terrible cook or not. Maybe he just wasn't hungry - I can ask him

WHAT ALTERNATIVES ARE THERE?

Am I assuming my view of things is the only one possible? How would you have looked at this situation before you got depressed? How would another person look at it? How would you look at it if someone else described it to you?

Automatic thought	Possible answer
That was a terrible mistake: I'll never learn to do this properly.	If I wasn't depressed, I'd probably shrug my shoulders and do what I could to set the situation right and learn from errors. Tom made just the same mistake last week, and he made a joke of it.

WHAT IS THE EFFECT OF THINKING THE WAY I DO?

1. What do I want? What are your goals. Do you want to be happy and get the most out of life? Is the way you are thinking now helping you to achieve this? Or is it standing in the way of what you want?

Automatic thought	Possible answer
I've wasted my life.	Brooding about the past only makes me depressed. The question is, what am I going to make of my future?

2. What are the advantages and disadvantages of thinking this way? Many distorted thought patterns do have some pay off - that is what keeps them going. But do the disadvantages outweigh the advantages? If so, you can think out a new way of looking at things which will give you the advantages, but avoid the disadvantages of the old way.

Automatic thought	Possible answer
I must make a good impression at this party. Advantage:- I'll go out of my way to talk to people. If they like me, I'll feel marvellous. Disadvantage:- If someone doesn't like me, I'll feel terrible and think badly of myself.	Telling myself I must make a good impression just puts pressure on me, and will make it difficult to relax and enjoy myself. It is impossible for everyone to like me all the time. It's very nice when they do, but if they don't, it's not the end of the world.

3. Am I asking questions that have no answer? Questions like "How can I undo the past?", "Why aren't I different?", "What is the meaning of life?", "Why does this always happen to me?", "Why is life so unfair?". Brooding over questions like these is a guaranteed way to depress yourself. If you can turn them into answerable questions, so much the better. If not, don't waste time on them.

Automatic thought	Possible answer
When will I do better again	There's no answer to that. Going over and over it just makes me worried and upset. I'd do better to work out what I can do to help myself get over this depression as quickly as possible.

WHAT THINKING ERRORS AM I MAKING?

1. Am I thinking in "all or nothing" terms? Nearly everything is relative. People, for instance, are not usually all good or all bad. They are a mixture of the two. Are you applying this kind of black-and-white thinking to yourself?

Automatic thought	Possible answer
I did that really badly	The fact is, you didn't do it as well as you wanted to. That doesn't mean it was no good at all. You can't expect to do everything 100% right. If you do, you'll never be satisfied.

2. Am I using ultimatum words in my thinking? Watch out for words like always/never, everyone/nothing. The chances are that the situation is actually less clear - cut than that. Mostly it's a case of sometimes, some people and some things.

Automatic thought	Possible answer
Everything always goes badly for me.	That's an exaggeration. Some things go badly for me, just like they do for anyone else, but some things go well.

3. Am I condemning myself as a total person on the basis of a single event?

Depressed people often take difficulties to mean that they have no value at all as a person. Are you making this kind of blanket judgement?

Automatic thoughts	Possible answer
I was so irritable with the children this morning. I'm a terrible mother and a wicked person.	The fact that on a particular day, at a particular time, in particular circumstances, I was irritable, does not mean I'm a terrible mother or a wicked person. I can't reasonably expect never to be irritable and making myself depressed by writing myself off completely is not going to help me to be nicer to the children when they get in from school.

4. Am I concentrating on my weakness and forgetting my strengths? When people become depressed, they often overlook problems they handled successfully in the past, and resources which would help them to overcome current difficulties. Once they change their thinking, they are often amazed at their ability to deal with problems. How have they coped with similar difficulties in the past?

Automatic thought	Possible answer
I can't stand being alone, now that Jane has gone.	I was alone before I met her. I made an effort to get out and meet people, and spent time doing things I enjoyed. In fact, I was quite happy - and probably can be again. I'll 'phone Bob for a start.

5. Am I blaming myself for something which is not really my fault? Depressed people, for instance, blame themselves for being depressed. They put it down to lack of willpower, or weakness, and criticise themselves for not "pulling themselves together" .In fact, scientists have been studying depression for many years, and they are still not certain what causes it. Depression is a difficult problem to solve, and blaming yourself for it will only make you more depressed.

Automatic thought	Possible answer
I must really be stupid to have these distorted thoughts.	Stupidity is, one possible reason. When I look at myself as a whole, there's not much evidence that I'm stupid. I have these thoughts because I'm depressed. When I'm feeling better, I think quite differently.

6. Am I taking something personally which has little or nothing to do with me? When things go wrong, depressed people often believe that in some way this is directed at them personally, or caused by them. In fact it may have nothing to do with them.

Automatic thought	Possible answer
Mary doesn't like me at all. She would never have shouted at me like that if she did.	I'm not the only person Mary shouts at. She's always on edge when things aren't going well for her, and she shouts at whoever is around. I've seen her. She'll get over it and probably apologise.

7. Am I expecting myself to be perfect? It is simply not possible to get everything right all the time. Depressed people often set unrealistically high standards for themselves. They then condemn themselves for making mistakes, or acting in ways they would rather not have done. Accepting that you can't be perfect does not mean you have to give up trying to do things well. It means that you can learn from your difficulties and mistakes, instead of being upset and paralysed by them.

Automatic Thought	Possible answer
This is not good enough. I should have completed every thing I planned to do.	I can't always expect to carry out everything I plan. I'm not God,I'm fallible, like any otherhuman being. It would have been nice if I had finished, but the fact that I haven't is not a disaster. Focus on what you have done, not on what you have failed to do. That way you will be encouraged to try again.

8. Am I using double standards? You may be expecting more of yourself than you would of another person. How would you react to someone else in your situation? Would you be so hard on them? You can afford to be kind to yourself as you would to someone else. It won't lead to collapse.

Automatic thought	Possible answer
I'm pathetic. I shouldn't be so upset by things.	If someone else was upset by this situation, I'd be sympathetic towards them, and try to help them try to find a solution to the problem. I certainly wouldn't call them pathetic - I'd be able to see that it wouldn't help. I can do the same for myself. It will give me the courage to carry on.

9. Am I paying attention only to the black side of things? Are you, for instance, focusing on everything that has gone wrong during the day, and forgetting or discounting things you have enjoyed or achieved?

Automatic thought	Possible answer
That was really a terrible day.	Hang on a moment. You were late for a meeting, and you had a disagreement with your son, but on the whole your work went well, and you enjoyed the cinema this evening. It wasn't a bad day. Only remembering the bad things is part of depression - watch out for it.

10. Am I overestimating the chances of disaster? Depressed people often believe that if things go wrong in any way at all, disaster is sure to follow. If the day starts badly, it can only get worse. How likely is it that what you expect will really happen? Is there really nothing you can do to change the course of events?

Automatic thought	Possible answer
I didn't get all my work done today again. I'll get the sack.	When was the last time they sacked someone from this firm for not having time to finish the job? It's perfectly normal not to finish, when we all have to work under such pressure. If my boss comments I can explain the situation to him.

11. Am I exaggerating the importance of events? What difference does a particular event really make to your life? What will you make of it in a week, a year, 10 years? Will anyone else remember what you now see as a terrible thing today? If you do, will you feel the same way about it? Probably not.

Automatic thought	Possible answer
I made a real fool of myself at that party. I'll never be able to face them again.	Don't make a mountain out of a mole hill. Most people didn't even notice. I don't suppose anyone who did thought anything much of it. We'll probably laugh at it in the future - it certainly makes a good story.

12. Am I fretting about the way things ought to be, instead of accepting and dealing with them as they are? Are you allowing events in the world at large to feed your depression? Telling yourself life is unjust, and people are brutes? It is sad that there is so much suffering in the world, and you may have tried to do what you can to change things, but getting depressed about it does nothing to help.

Automatic thought	Possible answer
That programme about old people in the slum was awful. Things should be different.	Things are as they are, and to want them to be different is counter to reality - like wishing the zebra had no stripes. Getting depressed about it is not going to help the situation. Why not see if I can visit someone at the Old People's Home down the road or help an elderly neighbour?

13. Am I assuming I can do nothing to change my situation? Pessimism about the chances of changing things is central to depression. It makes you give up before you start. You can't know that there is no solution to your problem until you try. Is the way you are thinking helping you to find answers, or is it making you turn down possible solutions without even giving them a go?

Automatic thought	Possible answer
It's no good. I'll never sort this out.	If you tell yourself that, you certainly won't .Sit down and work out what you could do. Even if some of your solutions haven't worked before, that does not mean they won't now. what was it that stopped them from working?

14. Am I predicting the future instead of experimenting with it? The fact that you have acted in a certain way in the past does not mean to say that you have to do so in the future. If you predict the future, instead of trying something different, you are cutting yourself off from the chance of change. Change may be difficult but it is not impossible.

Automatic thought	Possible answer
I'll never manage to stand up for myself. I never have.	The fact that I never have does not mean I never can. Doing so will make me feel uncomfortable, but if I stick with it, will become more natural. Also other people will respect me more.

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