DEFEATING DEPRESSION
Continued from Chapters 1 to 8
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CHAPTER 9
Arguing against your negative automatic thoughts may not be enough by itself to convince you that they are incorrect. You will need to build up a body of experience which contradicts them. The best way to do this is to act on your rational answers and discover for yourself whether they are in line with reality and helpful to you, or whether they need altering. Action helps you to break old habits of thinking and strengthens new ones.
TESTING OUT PREDICTIONS
People are like scientists. We make predictions ("If I press the bell, the bus will stop"., "People don't like to be contradicted". "If I stand in the rain, I will get cold"), and we act on them. We use information from our experiences to confirm or change them. A depressed person is like a scientist gone wrong. He distorts experience to fit his negative beliefs, instead of using it to prove or change them.
Many negative thoughts take the form of predictions ("I won't be able to do it"; "Everyone will despise me"; "If I say what I think, I will be rejected"). In normal life we often act like scientists but we are not conscious of this. If we predict something, we check out whether we were right or not and if not, we try to find out what went wrong and then either change this or modify our prediction. However in depression we stop doing this and also have negative predictions. If our predictions are wrong, i.e.. things work out well - we distort the evidence, 'it was a fluke' or 'they are just being kind to me' etc. Below is a way of acting more rationally. By following these steps you will be able to overcome the depressed way of thinking and acting. It is similar to the way a scientist would do an experiment.
| a. If your prediction is not borne out (i.e. your negative thought is shown to be false), so much the better - you have demonstrated a positive alternative in action. |
| b. If your prediction is borne out (i.e. the negative thought is shown to be correct), do not despair. This is also valuable information. what were you doing to bring about this result? Can you work out ways of acting and thinking differently in future so as to bring about a more positive result? Once you have done so, set up another experiment. |
Two examples follow:
EXAMPLE 1
Peter is studying engineering. In class he never asks questions because is afraid of looking stupid.
If I was stupid, I wouldn't be in this class in the first place. Ignorance is not the same as stupidity - at this stage in the course there are bound to be many things I don't know. I don't think other people are stupid because they ask questions - I wish I had the courage to do the same. And I have no evidence that other people think them stupid - in fact, the lecturer encourages questions. Asking questions is the best way to learn.
Lots of questions asked, and no bad reactions that I could see. Several questions led to stimulating discussions. The Lecturer said one question was good which I would have asked, if I had the nerve. Jim asked a couple of "stupid" questions, (obvious answers), but it wasn't a disaster - everyone laughed, including him
On the evidence, no one is likely to think me stupid for asking questions. Even if a question was stupid, it need not be a disaster - it doesn't mean I am stupid.
EXAMPLE 2
Sarah has been invited to a party. The thought of it fills her with panic. She is convinced that she will have nothing to say to anyone, and will not enjoy herself. This depressed her, because she believes that she will lose contact with all her friends.
Before I got depressed, I used to enjoy parties. It's true that since I got depressed I haven't got much pleasure out of most of them. Still, there have been one or two I enjoyed. This will be all old friends. They know how I've been and won't expect a lot of me. If I don't go, I will miss the opportunity for pleasure, which will make me feel better if it works out.
Try it and see, use distraction techniques beforehand to prevent build-up of anxiety. Talk to people I know first. Relax and listen.
Did not enjoy it Left early. Why? Spent the whole evening thinking how happy everyone else looked and telling myself how different things were for me. So busy thinking about myself, I couldn't concentrate on anything that was going on.
Prediction correct, but mainly because I was so preoccupied with negative thoughts. Even so, two friends rang today, so one bad evening does not mean I'll completely lose contact.
Next time, work harder at answering negative thoughts beforehand, and counting them off and distracting myself during the party. Practice distraction exercises in the meantime.
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CHAPTER 10
If you have been able to use the suggestions given so far you will probably be feeling a little better by now and feel more in control of your depression. It is now time to look at the beliefs that make you vulnerable to depression. These beliefs are sometimes called dysfunctional assumptions. They are called this because all beliefs are assumptions not facts. They are dysfunctional because they ultimately inhibit your happiness and ability to live up to your full potential.
Dysfunctional assumptions usually originate from experiences in childhood or from attitudes and beliefs that you have picked up from your parents or other significant people in your childhood. They may well be based upon family rules. These rules would have been very apparent to you as a child as you would have heard them spoken day in, day out. Sometimes as a child they are very useful as they are meant to be guidelines rather than rigid rules. A well known rule is children should be seen and not heard. Maybe this is not accepted very much nowadays but was quite common in days gone by. However if you stick with this rule throughout your life, you are likely to become very unassertive and as an adult, if this rule persists, you are very unlikely to get your needs met. Because people never talk to you about these rules, now they have often become out of your awareness but nevertheless you still often act upon them. Many of these rules appear to be shared by large sections of the population. However in reality most people do not hold the rule in such an extreme way and allow themselves opportunities to avoid the rule in certain circumstances. Thus it is normally only the intensity or extremeness of the rule that is different in people who are prone to depression.
Below are several examples of common dysfunctional assumptions:-
You may recognise some of these or something similar.
Your dysfunctional assumptions may be quite different and at this stage you may not even be able to recognise any. Do not despair because there are some ideas below to help you become aware of these.
However it is often very difficult to recognise these assumptions because: -
Despite this it is worth while trying to recognise them and overcoming them. This stage can be quite prolonged as these assumptions are deeply entrenched therefore dislodging them and creating a healthy rule in its place can take time and practice.
IDENTIFYING DYSFUNCTIONAL ASSUMPTIONS
Dysfunctional Assumptions can be active in all areas of your life but the areas concerning acceptance / rejection / success / failure / health / sickness and loss are the most frequently encountered. As mentioned before these assumptions arose in your childhood. At this time in your life others do a lot of your thinking for you - parents, teachers etc.. but now it is time to start to think for yourself to see if these assumptions really make sense to you now in the-. present.
The way you recognise dysfunctional assumptions is to use the daily record of dysfunctional thoughts to collect your negative automatic thoughts. Over time, as you begin to recognise these thoughts you will also start to see general themes in these. With time these general themes can be formulated into more specific rules i.e. your dysfunctional assumptions. This is because Negative Automatic Thoughts usually stern from the dysfunctional assumption. If you believe the assumption, the Negative Automatic Thought seems logical but if you do not, it becomes untenable.
The following Negative Automatic Thoughts were reported by a patient:-
As you can see all these things are about the way the person was performing and underlying this was an assumption about the need to be perfect to be loved. It is important to try to pinpoint the assumption as accurately as possible, that is try to put it in your own words.
The following will help you identify your dysfunctional assumptions.
However a word of caution, because your assumptions started in childhood, the views of grandparents, parents, brothers and sisters may all be tinged with the same assumption so they may be reinforcing the assumption i.e. it is a family rule therefore great caution needs to be exercised in this area. These family members may hinder your recognition of the assumptions as much as they will help you identify it.
Thought |
Question |
| I was not able to join in the conversation. | What does that mean? |
| It means I am a poor conversationalist | If you were a poor conversationalist then what? |
| My friend Richard would not like me | And if he did not like you then what? |
| He would not be my friend | What is so bad about that? |
| Well if he was not my friend, who would be? | And what would that mean to you? |
| I would be alone forever. |
At this stage it is easy to see why you would feel depressed or for that matter, anyone else would do. However compare the first statement 'I was not able to join in the conversation' and see what it leads to 'I will be alone forever' .The initial statement is in conscious awareness, the end statement is not and therefore it has to be searched for. In this technique you must keep asking questions until you have got to a statement that everyone would agree would lead them to feeling sad. If you get stuck somewhere and the statement is not that emotionally laden, you have probably taken a side track - this is quite common so do not criticise yourself go back and try again. If you still come up with nothing stop and try again another time with a different thought. You may find it helpful to write it down as above -using the 'downward arrows' from which the technique gets its name.
MODIFYING ASSUMPTIONS
The identification of assumptions is clearly the first step in changing them so in one sense you have already begun. You may have already seen the inappropriateness of your assumptions and the almost impossible task you have set yourself if you try to live by them.
As you try to overcome your assumptions you must try to find arguments that make sense to you. One argument or statement that makes good sense to you will be more effective than several that whilst they have been true, do not have much meaning to you.
MODIFYING THE "SHOULDS"
"Should" in a statement often implies an assumption or rule of living and it is often dysfunctional. Be aware of situations in which you are responding to a 'should'. Check with yourself if you are comparing what you are doing with what you should be doing. If you are using 'shoulds', you will probably find that you will be responding to a situation more intensely than others would and in more varied situations e.g. the person who says "I should always have my house tidy" would probably have everything in just the right place and it would always would be so.
Check what the consequences are of not obeying the 'should' i.e. why 'should' you keep the house tidy. Other alternatives to shoulds are "musts" and "have to's" - these are just the same as 'shoulds'.
One way of overcoming the 'shoulds' is response prevention i.e. prevent yourself responding to the 'should'; do not do what the 'should' implies and observe what happens. Does the consequence of not obeying the 'should' apply, if not, the rule needs to be modified.
In order to use this method success fully you need to set yourself tasks of increasing difficulty i.e. only slightly against the 'should' first and then gradually increasing e.g. if you believed you should always be nice to someone you want to like you. The first task may be to confront your husband or wife on some minor difference. You would then move on to something more risky etc. You may find it helpful to rehearse this beforehand i.e. work out what you are going to say and what the response will be and then any counter arguments. Estimate how upset you or the other person will be and for how long and also whether it will have any long term effect on the relationship.
The outcome is usually that you will develop a more flexible rule so that the 'should' becomes replaced with other less extreme words like 'usually, mostly, whenever, possible' etc. These allow for exceptions when other things take priority e.g. rather than I must be on time the rule becomes whenever possible or usually I will try to.
Recording the consequences of obeying the shoulds can also often be very instructive. You could try recording what happens every time you obey a 'should' for a whole week. Does the predicted beneficial consequence occur - do people notice or appreciate you or do they ignore, take advantage or criticise you because of it.
ASSUMPTIONS AS PERSONAL CONTRACTS
Most of us use the concept of deserving or justice i.e. that if we do something good we deserve a reward and if we do something bad, justice should exert a penalty. This leads us into various behaviours in order to earn rewards and to avoid the punishments. This is normal and natural. However the depressed person sets up contracts with themselves that are too severe or rigid.
Within the contract is a reward for a particular behaviour e.g. if I put other's needs first (behaviour) then they will respect and love me (reward). Such contracts are often vague and open-ended e.g. to what extent should other's needs be put first and the contract is a life sentence.
The concept of fairness often becomes implicated because you expect that others will respond accordingly to your rule even though they do not share it. The reality is that life is not fair and people are not equal. You may wish it were otherwise but the fact is that some people are wiser, stronger, richer and more powerful than others. Some people enjoy good health whilst others endure bad health through no fault of their own. You have to learn to accept the unfairness of life.
Try making a list of situations that are unfair and what you can do to change them. Some of the things you will not be able to do anything about as they are beyond your control - but you can change your attitude towards these. However some of the unfair situations may be in your control so make a plan of action to put things right and then do it. Also try looking at the situation from other peoples view point as fairness is often a matter of opinion rather than an absolute fact.
Fairness is an abstract concept that is impossible to define accurately. Therefore trying to attain fairness is very difficult. You should try to look at the world in a more down to earth way and make judgements about what you want to achieve and how to go about getting it. If the goal is attainable and worth the effort you are much more likely to achieve it.
When modifying your rules be careful not to flip over to the opposite pole. Most "shoulds" are too pervasive and intense. Therefore all that needs to be done is to reduce the intensity and allow for exceptions and to reduce the area that they cover.
SELF FULFILLING PROPHECIES
Most dysfunctional assumptions are self fulfilling prophecies. By predicting a certain emotional response to a situation it invariably happens. If you tell yourself you cannot be happy if you are not successful, loved, respected etc., then you will not be. However look around you and see if there are people in these same situations and who are happy. Not all will be but some certainly are. As you learnt earlier, the way you think determines the way you feel. Changing your belief is not simple it requires practice and repetition therefore keep reminding yourself -write down your new belief on a card and read it several times each day and look at it if you are feeling down.
If you believe that you cannot be happy if you do not have a close relationship, change this to something else:- e.g. although it is very good to have a close relationship there are lots of other things in life that bring me pleasure therefore I can be happy without a close relationship.
LIST ADVANTAGES AND DISADVANTAGES OF DYSFUNCTIONAL ASSUMPTIONS
Often you may be able to identify your dysfunctional assumption and recognise the advantages of changing this but be afraid to do so because of the disadvantages you can also see of changing. So make a list of all the advantages and all the disadvantages of changing your dysfunctional assumptions. Try to identify all the possible consequences of changing the dysfunctional attitude. Then look at the disadvantages and look at whether they are accurate or whether they are effected by the thinking errors we met earlier in this book.
Although this seems a very simple thing it is amazing how effective it can be. You have probably only really considered the disadvantages of changing your belief or have not explored the advantages of changing sufficiently well enough. So have a go and see what happens.
THE ROLE OF ACTION IN CHANGING ASSUMPTIONS
Once you have challenged your assumptions and developed some new rules, putting them into action is the next step and most important step. It can change something that you believe to be true to something that you know to be true.
To know something you have to experience it.
You have to force yourself into action and stay with it for long enough. You will feel uncomfortable at first - often this will fade after ½ - 1 hour of behaving in the new way but will return again when you try it again. However as you keep repeating the action the discomfort will gradually get less and it will be easier and easier. If anxiety is a major problem in these situations learn how to relax and control your anxiety - there is a sister guide to this one called "Managing Anxiety" This will be added to this website as soon as possible. So try to read it when available and follow its instructions, many are similar to those in this guide.
IMPROVING SELF ESTEEM
Self esteem is in effect a theory you have about yourself and about your value to others. Depressed people usually have a low level of self esteem. Improving self esteem can be very difficult for you at this time. You probably determine your worth in comparison to others. This is fraught with danger as you will tend to compare yourself to someone you perceive as being better e.g. your boss at work or a friend, however that person may feel inferior to someone else. There will always be someone who has more of a particular characteristic than you.
You will also tend to make global assumptions e.g. if a person is good at one thing you will assume they are good at everything or that the other things are unimportant. However you are unlikely to be so generous to yourself.
The best way to overcome low self esteem is to not bother with it at all as it is impossible to measure anyway - is a successful businessman/pop star or politician more worthy than you? Remember all the stories that come out about these people, they all have their faults and are unworthy' in some way.
Another way to improve your self esteem is to tell yourself that just being a human being makes yourself worth while. In effect "I am, therefore I am good" .Doing this might be quite effective for a period of time and may tide you over until you are feeling less depressed. When the depression has lifted you should make a list of all of your positive points and all of your negative points. You will probably be surprised at how many positive points there are and also be able to take a more rational view of the negative ones. You may well be able to work on changing some of the negative ones using some of the ideas from this guide. However you may have to accept that some of these may be difficult to change and learn to live with them or perhaps see them in a different way. Sometimes some of the things we see as negative, other people see as positive attributes for example stubbornness. Stubborn people can often use their refusal to change to force through things other people would give up on.
You should avoid comparing yourself with other people as you will almost certainly chose someone with whom you compare unfavourably. However there is probably always someone better than yourself and probably always someone worse than yourself on any particular characteristic. When depressed your thinking is so distorted that it would be impossible for you to be rational about this and therefore it is most important that you avoid comparing yourself at all with others.
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CHAPTER 11
We are constantly faced with problems to solve. Most of these do not pose too much difficulty for us. However we are occasionally faced with more difficult problems for which we cannot easily find a solution. This chapter discusses a tried and tested method for solving problems. The method can sometimes take quite a bit of time to go through so give yourself the time to use it. Remember that the problem itself will take up more time if you do not solve it.
Forces For |
Forces Against |
| 1. I have a good relationship with her. | 1. Her boyfriend will try to sabotage |
| 2. She likes to be part of making decisions | 2. She is not often around when I am |
| 3. My partner will support me |
These lists should be as exhaustive as possible. Separate lists should be made for each solution.
- 1. Talk with partner tonight during evening meal.
- 2. Talk to boyfriend tomorrow.
- 3. Discuss problem with daughter when we go out together on Wednesday.
Note that specific times and situations are chosen and specific actions. This is important to ensure you know what to do and if you have done it.
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CHAPTER 12
As mentioned earlier in this booklet, biological factors may play a major part in the onset of depression. Even when there are obvious stressful events causing the depression your doctor may recommend drugs to help you. In the main, drugs and the advice given in this booklet are complementary - they help each other. It is important therefore that you take any medications your doctor prescribes. If you have any doubts about your medication discuss these with your doctor. Most antidepressants do not work immediately and you will probably have to take them for at least 10 days before you notice any improvement and may be even longer. Therefore do not be discouraged too easily. Also you will need to keep taking medication for a few months after getting better. Your doctor will advise you about this. There are many antidepressant drugs available and below you will find 'some information about many of the more commonly prescribed ones. Antidepressants like all other drugs have an scientific name and one or more brand names. The brand name will appear in brackets below.
Antidepressants fall into several categories and these will be used in the sections below. If you are concerned about any of the information given do not stop your medication - discuss it with your doctor.
TRICYCLIC ANTIDEPRESSANTS (TCA)
Until a few years ago these were the main antidepressants in use. They are very effective antidepressants. There are several antidepressants in this group:-
Amitriptyline - (Tryptizol)
Imipramine - (Tofranil)
Clomipramine - (Anafranil)
Dothiepin - (Dothapax, Prothiaden)
Lofepramine - (Gamanil)
Protriptyline - (Concordin)
Most of these drugs remain in the blood stream long enough to make it possible to only take them once a day - although you will usually need more than one tablet.
Most of these drugs can cause side effects. These side effects are usually mild and more of a nuisance than being serious. However they can occasionally be more troublesome. The main side effects are:-
1. Constipation - if this becomes a major problem try to increase the fibre content in your diet. Eat wholemeal bread, cereals (Weetabix, Shredded Wheat, Shreddies, Allbran, Branflakes etc.) brown rice, wholemeal pasta and more fruit and vegetables. If this is ineffective seek the advice of your doctor.
2. Dry mouth - try sucking sweets, chewing gum or taking regular sips of water. This side effect usually gets less after a few days.
3. Blurred vision - you may find it difficult to focus on reading and watching the television. This tends to be intermittent and usually improves after a few days. No harm is done to your eyes so do not worry about this.
4. Sedation - you may be advised to take your medication at bedtime because of sedation, especially if the depression has affected your sleep. It could therefore be a help rather than a hindrance. Some antidepressants are less likely to cause sedation so if this is a major problem, talk to your doctor as he may be able to recommend a different antidepressant.
5. Weight gain - dieting does not usually help if you are eating normally. You may just have to put up with the weight gain until it is time to stop your medication. Remember that it is probably worth it to overcome your depression. You should be able to loose the weight again when you stop your medication.
6. Low blood pressure - this is unusual in younger people. It tends to occur when you get up from sitting or lying down. The blood pressure drops making you feel faint. Getting up more slowly and steadying yourself helps. The blood pressure usually comes up again within a few seconds and then things will be O.K. again. If this is a serious problem, see your doctor as soon as possible and he will advise you further.
7. Difficulty in passing urine - usually only occurs in older men and then only rarely. If this becomes a problem you need to see your doctor.
8. Sweating. This can be episodic and at times quite profuse but fortunately is not a common side effect.
All of these side effects tend to subside with time and tend to be less troublesome if the dose is built up over a few days.
SSRI'S
SSRI stands for Specific Serotoniin Reuptake Inhibitors which describes their action in the brain. Their action is more precise than the TCA's and this results in less side effects. These drugs are becoming more popular. They are taken once a day and usually in the morning or at lunch time with food. Drugs in this group include:-
Fluoxetine (Prozac)
Fluvoxamine (Faverin)
Paroxetine (Seroxat)
Sertraline (Lustral)
They are equally effective and the only common side effect is nausea. This affects 10-20% of people. Nausea may be less of a problem if the drugs are taken with food. Occasionally the drugs may disturb your sleep therefore taking them earlier in the day will help with this.
MAOI
MAOI stands for Mono Amine Oxidase Inhibitor. Again this describes the actions of the drug. MAOI's are less popular than other antidepressants. Since their action is different from other antidepressants they may be tried when other antidepressants have failed. They are also said to be useful in atypical depressions in which anxiety may be a central feature. The side effect profile is similar to the TCA's (see above). However they also have another complication which is why they are used less commonly. MAOI's interact with a substance called tyramine. This is present in certain foods. This means that these foods have to be avoided. Foods in this list include cheese, yeast products (Marmite, Bovril, Oxo etc.), gravy, pickled herrings and certain red wines, especially Chianti. These drugs also interact with codeine and similar drugs. These are often found in pain killers and cough and cold cures so you need to check with the chemist when buying such medicines that they are safe to take with MAOI's .The drugs in this group include:-
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Isocarboxazid
There is a newer type of MAOI which has a decreased interaction with tyramine therefore allowing small quantities of these foods to be eaten. This is called:
moclobemide (Manerix).
OTHERS
There are other antidepressants that do not fall into these groups above. They are usually similar to the TCA's but with a reduced incidence of side effects. They are not usually chemically related to TCA's or to each other. They include:-
Mianserin (Bolvidon, Norval)
Viloxazine(Vivalan)
Trazodone (Molipaxin)
MOOD STABILISERS
These drugs are used mainly in people who have recurrent depressions. They are not usually started by G.P's. The aim is to prevent rather than cure depression. However they may be added to other anti-depressants if the depression does not respond to a single drug. If they are being used to prevent depression, then they will need to be taken for months or years. The three drugs used are:-
Lithium (Priadel, Camcolil, Phasal, Liskonium, and Litarex)
Carbamazepine. (Tegretol)
Valproate (Epilim)
Since these drugs are not related, the side effect profile is different. They may need to be monitored by blood tests. For further information about these drugs, you should see your doctor.
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WEEKLY ACTIVITY TABLE
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8-9 |
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Grade your activities for Achievement (A) and Pleasure (P)
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DAILY ACTIVITY TABLE
DAY |
DAY |
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TIME |
ACTIVITY |
M 0-10 |
P 0-10 |
TIME |
ACTIVITY |
M 0-10 |
P 0-10 |
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DAILY RECORD OF DYSFUNCTIONAL THOUGHTS
DATE |
SITUATION 1. actual event leading to unpleasant emotion or; 2. Stream of thoughts, daydream or recollection, leading to unpleasant emotion. |
EMOTIONS 1. Specify sad, anxious, angry etc. 2. Rate degree of emotion 1-100% |
AUTOMATIC
THOUGHTS 1. Write automatic thought(s), emotion(s). 2. Rate belief in automatic thought(s) 0-100% |
RATIONAL
RESPONSE 1. Write rational response to automatic thought(s) 2. Rate belief in rational response 0-100% |
OUTCOME 1. Re-rate belief in automatic thought(s) 0-100% 2. Specify and rate subsequent emotions, 0-100% |
EXPLANATION: When you experience an unpleasant emotion, note the situation that seemed to stimulate the emotion. (If the emotion occurred while you were thinking, daydreaming etc., please note this). Then note the automatic thought associated with the emotion.
Record the degree to which you believe this thought: 0% = not at all; 100% = completely. In rating degree of emotion, 1= a trace and 100 = the most intense possible.
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The original guide which is freely available from Health Professionals at the Mental Health clinic locally is understood to have been written by Dr. G. Tomlinson to whom the original copyright must belong.
In his acknowledgements, it is stated that "Much of the information in this booklet is based on information in leaflets produced by Professor A.T. Beck and his colleagues for the Centre for Cognitive Therapy in Philadelphia"
The material is so clearly written and is known to have significantly helped a number of persons that it seems to call out for a wider audience via a presence on the web so this site has been created especially for the purpose of sharing it. It has been a long task to transfer but this will have been worth it if it helps just one person. The website author suffers from depression and has used the techniques outlined here (and still does so whenever necessary) to defeat the problem. You can do so too. Good Luck.
The companion guide on 'Managing Anxiety' will be published on this site as soon as possible.
This adaptation for the WWW and setting in HTML Copyright A.C.P.A. "The Lighthouse" 2000
Page created 26th May 2000
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