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Overcoming Depression One Step at at Time

By Thanos Napolias, MA

As any living being can attest, problems are unavoidable. Some problems are simple and their solutions are relatively immediate, such as figuring out an alternative route to work when there is heavy traffic and running late to work. Other problems are more distressing and complex, like dealing with an unexpected expense that throws an entire family out of budget. In both cases though, it’s essential to carefully examine the problem and then apply specific solutions to address each aspect, one at a time.

Like most mental health concerns, depression can be seen as a problem, since it causes significant distress and functional impairment for over 15,000,000 American adults each year, according to the Anxiety and Depression Association of America.  Therefore, when it comes to depression, a similar strategy of examining the problem and applying specific solutions to address each aspect can enable individuals who struggle to overcome their symptoms. Even though mental health challenges seem more complex than everyday unwelcome matters, therapy models that concretely address the various parts of depression have been showed to be very effective.

Traditional Cognitive Behavior Therapy conceptualizes depressive concerns as having four parts: (1) Negative emotions, (2) Distressing physiological responses, (3) Maladaptive cognitions (thinking), and (4) Maladaptive behaviors. As such, the first step in Cognitive Behavior Therapy for depression is to teach individuals to break down their experiences into these four parts, in order to come up with step-by-step solutions to each one.

For instance, we can think of a fictional person “Sally”, who is a college student experiencing depression. Sally feels sad all the time and is also afraid that she has fallen too far behind with her assignments (negative emotions). Sally also has no energy to attend her classes, feels tense in her neck and back, and she has a hard time falling asleep at night (distressing physiological responses). As a result, Sally starts to think of herself as a failure and wonders whether she will be able to graduate (maladaptive thinking), and she starts to spend more and more of each day in bed, avoiding classes, exercise, and social activities (maladaptive behaviors).

When Sally came to us for therapy, using the above cognitive-behavioral approach we helped her to realize that when a stressor came up she tended to feel sad, down, and somewhat anxious. On a thinking level, she tended to make unhelpful predictions about her future and for herself, such as “I am going to fail that class,” “The professor will think that I am lazy,” “Even if I try to go out with my friends, I will feel as miserable as staying in bed.” When she thought this way, it triggered Sally’s physiological sensations such as tiredness, muscle tension, as well as feeling “unreal and detached” from the world. In these difficult moments, Sally’s behaviors included staying in bed, withdrawing from friends, dropping out of her favorite workout class, and avoiding returning to her classes, which paradoxically reinforced her unhelpful thoughts and feelings.

Once Sally understood how her feelings, thoughts, sensations, and behaviors worked together to maintain her depression, she began with the help of her therapist to identify more helpful interpretations about her stressors and adopt small behavioral changes that significantly reduced her depression. With appropriate guidance, Sally made gradual shifts in her behavioral patterns, such as returning to her work out class and inviting a friend over, which had a positive impact on her mood and eliminated many emotional and physiological symptoms of sadness and fatigue. Similarly, over time she began to notice and challenge her unhelpful thoughts. At times she even tested her thoughts by approaching the professor and explaining her situation, and other times she started observing her thoughts without necessarily believing their content. Over time and with consistent practice, Sally overcame her depression, one step at a time.

Sally’s brief story is an example that mental health disorders are not permanent and that it is not overly simplistic to view them as problems to be overcome. Like Sally, individuals who struggle with depression can develop methods to live much happier and meaningful lives!


Have a Happy Summer!

Written by Peryl Agishtein

Ahh, the fresh smell of mowed grass… no school… and sun, sun, sun! Many of us remember summer as one of the most favorite and relaxing time of the year. Did anyone else count down the days until school was out? But once we grow up, and often work through the summer, and have kids out of school… and somehow summer morphs into a season marked with its own unique stressors.

Summer has a number of common stressors. Changes in routine (e.g., from school to vacation) come with the need for adjustments, which can be inherently stressful. Kids in particular may struggle to be flexible and stay even-keeled despite upended routines, which can lead to behavioral challenges and parental stress. Often there are even bigger changes that occur in the summer: Some families move houses or cities or take on new jobs, which can compound the general stress of routine changes. Another stressor that can arise in particular during the summer months relates to body image: Swimming and summer sports reveal more of our bodies, and even for those who forgo the pool, saying goodbye to sheltering coats and bulky sweaters can be cause for distress.

For parents of school-aged children, one particularly taxing stressor is the traditional cry “I’m so booooorrrredd!” Children who are used to jam-packed schedules and to-do lists can find themselves at loose ends with ample free time (as can adults), and may depend on their parents to entertain them. Another stressor for parents can arise when children compare summer plans, which often leads to jealousy. Comparison-based jealousy is most problematic in communities where people of varying SES all live side-by-side, or share schools or camps. Children in these communities are easily exposed to what others have, which can sometimes be sharply contrasting to what they own. Sleepaway camp in particular serves as a ripe context for highlighting children’s possessions that are not revealed in school, such as entire wardrobes, linens, pillows, accouterments, canteen and trip allowances. Unfavorable comparisons in any of these areas can lead to jealousy, unhappy children, and parents feeling pressure to either spend more or say no to their children.

However, with the beautiful weather and time off, it’s important to seize the day and not let summery stressors take over. Each summer stressor has unique solutions, but here are some tools that can work across the board for all:

First, implement a detailed summer routine BEFORE the end of June. Routines can include unstructured free time to relax, but should be generally predictable and comfortable in order to reduce the stress of unpredictable changes and the cries of “I’m booored.” For parents, sit down with each child and help them write a list of activities and goals that they want to reach over the summer (ranging from the small, such as blowing bubbles or reading Harry Potter, to the large, such as learn to play guitar). Encourage your child to build time into their day to engage in those activities/ goals. If they do turn to you for entertainment, remind them of their list and transfer the responsibility for entertainment back to their shoulders. However, make sure that with the cessation of individual homework time, each child continues to get plenty of attention and time with their parents (including at least a bit of individual attention). This will help relieve the pressures of entertaining your child (as they won’t be seeking your attention as much) and will help foster secure children who are happier with what they have.

Second, try to experience and model contentment with your summer plans as well as positivity and enthusiasm for the small pleasures of summer (both in speech and in affect). Stay away from comparisons and gossiping in general. Why ruin a beautiful time of year? And make sure that you do take the time to relax, go swimming, barbecue, or do whatever it is that makes summer special in your family culture.

Who says grown-ups can’t look forward to summer?

When It’s More Than Just a Little Stress


Written by Talia Kaplan

Consider the following three people:

Joseph is a 35 year old married man whose father died from stomach cancer 5 years earlier. Recently, Joseph has begun to worry that he too may develop cancer. He has gone to several medical doctors and has had numerous scans, all indicating that he is healthy. Joseph continues to worry despite his doctor’s, his wife’s and his family’s reassurances. Any time Joseph feels nauseous or pain in his stomach he begins googling the symptoms to see if it is possibly stomach cancer. Joseph severely has limited the type of food he eats, stopped exercising, and stopped working due to his fear of stomach cancer. Recently, he has noticed that he is worrying about a hernia and other types of medical problems. When he went to see his general practitioner, he was referred to a therapist.

Nancy is a 60 year old divorced mother of three children who has a fear of flying on planes. Her three children live all across the United States, but Nancy has never been to visit her children due to her fear. She has never met her grandchild, and has become depressed as a result of her strained relationship with her children. Nancy’s daughter will be getting married in 2 months and she would like to be able to attend the wedding.

Michael is a 25 year old single male who obsessively worries about the remote possibility that he might kill someone, despite the fact that he has no desire to do so and zero history of violent behavior. Michael works as a barista in a coffee shop, but recently had to take a leave of absence because he kept thinking that he may have accidentally put detergent in a person’s coffee which might kill them. Michael would therefore re-do each cup of coffee he made three times before handing the cup to the customer. Michael’s supervisor noticed what he is doing and has threatened to fire Michael as a result of his inefficiency.

The three people listed above experience debilitating levels of anxiety. Their anxiety has moved beyond regular daily stress. It has moved beyond the frustration of frequently experiencing anxiety in difficult situations. For the people in these vignettes, anxiety has become the thing to fear, and a significantly inhibitory factor in their lives. The first person, Joseph, experiences hypochondriasis (health anxiety); Nancy has a specific phobia of airplanes; while Michael has OCD. While it is expected for all people to worry at times, anxiety can prevent people from living their life in the way they would want to. In cases like these intensive outpatient treatment involving exposure therapy, can help people make rapid gains in treatment over a short period of time.

Exposure therapy works on the premise of behavioral learning models. By avoiding the feared stimulus, people’s anxieties tend to get worse because their fears take over their life decisions. Exposure therapy re-teaches people that they can fully engage in life. Sometimes the feared outcome takes place, and sometimes it doesn’t, but their fear does not dictate whether it will happen. In intensive exposure-based treatment, the therapist and patient first work to ensure understanding of the core fear. For example, for some people the fear of flying in an airplane is that the plane may fall out of the sky, for others it may be that the airplane may hit turbulence and the passenger may experience nausea. Second, the therapist and patient collaborate to develop a hierarchy of feared situations. This hierarchy serves as a map for treatment progress. Patient and therapist then spend a series of half- or full-days together to move in a linear fashion to tackle areas of avoidance for each patient. An example of a first stage in a hierarchy for Michael might be thinking about a person spilling hot coffee on themselves and thereby slightly burning their hand because of a hot cup of coffee that he gave them. The therapist and patient work methodically to help the person re-engage fully in their lives despite feared situations. In many cases of intensive treatment, patients have seen significant improvement in their ability to live the life they want to be living within a week.

One important aspect of doing this type of short-term intensive treatment is attending to bodily sensations. For a patient like Joseph, bodily sensations are often interpreted as dangerous or scary. Through the use of mindfulness techniques, therapists work to teach patients how to re-interpret the daily aches and pains of daily life. Research suggests that intensive treatments can be used to help a person meet a short term goal that they have been struggling with for years. It can help a person reconnect and rebuild interpersonal relationships, allow a person to keep their job, and help people feel more satisfied with their lives.