How you could introduce
in a consultaTion
The Pulse campaign has highlighted GPs' frustration with lack of access to therapies. Dr Paul Gilbert suggests how GPs can adapt some of the ideas and procedures of CBT into a short consultation
Cognitive behaviour therapy suggests some of our moods and emotions are accentuated and maintained because of how we think about things the interpretation and meaning we place on events.
Aaron Beck, one of the originators of cognitive therapy, noticed that as people become depressed there is a change in the way they think about themselves, the world and their future. Basically, there is a shift to a more negative focus, a reduction in adaptive coping, and a tendency to ruminate on how bad things are and how bad one feels.
The practice points below are for mild depression.
Remember, we can only invite people to consider these ways of working with their depression in a collaborative way. Nevertheless, for some patients, these suggestions may be enough to get them started on the journey to recovery.
Explain and de-shame
Some people are ashamed of feeling depressed or that they are struggling to cope while others are unaware of why they feel unwell or very tired, so it is helpful if the GP can explain and de-shame depression. For example, one might say to a patient:
When we are under a lot of stress, or stress has gone on for some time, this can use up various chemicals in our brain and body. In effect we become emotionally and physically exhausted and depressed. When this happens our mind often shifts towards very negative conclusions and feelings about things.
This is not your fault, it is the way we can be when we are very stressed. But it is important to try as best we can, to see how the depression can
affect the way we think and behave. So we can try to stand back from the depression and develop a plan to work with this difficulty.
Some people like a label, eg 'depression', because it helps them recognise they do have a problem and that there is a treatment for it. Other people find it stigmatising
but might accept the concept of emotional exhaustion.
Depressed people tend to withdraw from the world (ruminate more) and feel worse. So discuss with the patient a schedule or even a daily plan of activities they can find useful. Build in things that need doing as well as pleasurable things. They should develop an activity list for the day and try to stick to it. For example if watching daytime television is a pleasure (rather than an escape) that can be done as a reward after more boring tasks.
Increasing social behaviour and encouraging people to be with others can be very important. Explore if they could make extra effort to talk to their friends. Explain that depression can push us to cut ourselves off from others but it is helpful to work against that.
Depressed patients tend to ruminate on why they feel so bad and the negative features of themselves, their world and their future. For example, following the break-up of a relationship, one person may have a period of grief, recognise what they are going through is most unpleasant but a normal
reaction, and use friends as supports.
A person prone to depression, however, may personalise the break-up and feel it was due to some characteristic about them (for instance they are boring or undesirable in some way).
They then predict that they won't be able to develop meaningful, intimate relationships and are destined to be emotionally alone. They may stop going out. If these conclusions are not bad enough they will then ruminate on how bad it will be now, given that they are going to be alone forever.
Here the GP can anticipate rumination and simply say to patients: 'When we get depressed it is quite natural for us to start ruminating on all the negative things in our lives, our symptoms and feelings. However, if possible, and to the best of your ability, try to notice when your mind is on that ruminative treadmill and refocus your attention.'
The idea in refocusing is to break the
loop between ruminating, feeling bad and ruminating. You can explain to patients
why ruminating is unhelpful by using some examples.
The way we think about things affects our emotions and our bodies. For example, if you are hungry and you see a meal this will make your mouth water and your saliva flow. However, just imagining a good meal could have the same effect because your images and thoughts stimulate those areas of your brain that control your stomach acids and saliva.
Planning a good holiday and just thinking about it can give us a burst of good feeling or excitement. This is all because our thoughts affect our bodies.
Equally, when we ruminate on stressful things we are stimulating stress hormones in our body and feel bad.
So, one thing we can try to do is keep track of our attention and, to the best of our ability, refocus our attention when we find it is ruminating on things that disturb and upset us. This may take some of the pressure off the stress system.
CBT is not about positive thinking, but balanced and less one-dimensional thinking. Nevertheless, it can be helpful to explain to some patients that when we are depressed we become so negative we can't hold any positive thoughts or feelings in our mind. Therefore we need to spend a little time
trying to reactivate those positive emotion systems.
We might do this by encouraging ourselves to do enjoyable things, even if we predict we will not enjoy them often the prediction turns out to be incorrect to some degree.
Another exercise we can try is to spend just five minutes a day practising focusing on what we like preferences in food, types of flower, or the type of weather.
If they are able, they can practise focusing on what they find helpful and can enjoy in their lives. If they are able they should try to take up a posture of enjoyment with a half or a gentle smile on their face, as this stimulates feedback to the brain of positive affect.
Once again, when they engage in this activity they should do so with a soothing rhythm to the breathing.
Explain this as a chance for the brain to get some balance from all of the negative thoughts. Positive focusing is not about 'looking on the bright side' or denying problems; it is a specific exercise to stimulate the positive feeling areas of our brain.
Depressed people can become very 'black and white' in their thinking. In fact, stress makes us all a bit more black and white. One can explore this with patients. For example, consider the case of the person who is self-blaming and self-derogatory for the break-up of an intimate relationship. The GP may say something like:
The breakdown of your relationship is very upsetting and stressful and this may be one reason you are feeling bad. However, I notice that you tend to blame yourself for this. I am wondering if that is being fair on you. Are there any other possibilities for the breakdown?
Although these attributional styles often are linked to childhood experiences, here the GP and the patient then actively collaborate and think about alternatives and turning 'black and white' into 'grey' areas. The GP may ask:
If you had a friend whose relationship had broken up, would you talk to them as you talk to yourself and blame them? (Usually the patient understands this would be unkind and unhelpful and would make their friend feel worse.)
So what would you say to help a friend who was distressed about the loss of their relationship? [or] What could a friend say to you that you find helpful right now? What action might that lead you to if you listened to your friend?
Because patients get exhausted they can feel overwhelmed with their problems; it just seems like one big black mass of difficulties.
Problem solving involves discussing and recognising this. One way to approach this
is to break problems down into specific
For example, one might develop a problem list and then think about prioritising the problems. Prioritising can have two aspects. One is based on the importance or difficulty of the problem, the other is based on how easy it might be to deal with.
Both of these need to be considered because one shouldn't assume that one goes for the most difficult problem first (because that is a top priority). Success at solving the easier problems can sometimes spin off into having confidence in dealing with the more difficult ones.
Think through what people may need to help with the problems and then the steps for getting that help or some solution. If the problem is irresolvable then it is how to accept, come to terms and live with it.
Breaking things down into small steps can be helpful to depressed people, who can struggle to think like this and be good at planning.
Paul Gilbert is professor of clinical psychology, University of Derby, and author of Overcoming Depression. His book is available in areas where the Books on Prescription scheme applies, and throughout Wales under Book Prescription Wales. To purchase a copy go to www.overcoming.co.uk