Ask class what their objectives are with taking this class.
Break class into 3 teams and hand out the Myth and Fact signs.Rules: I will be reading a statement. As a group decide if it is a Fact or Myth about depression. Once you have decided as a group, hold up the sheet with your answer. After each answer, I will be reading a follow up statement.
(Refer to slide first)“These are gloomy statistics but…2 hopeful points: First of all, how many of you felt you could relate to the video/song from the beginning of class?...so the first hopeful point, is that if you are depressed, you are not alone. So many times people feel utterly alone in their suffering. Depression is a tremendously common human condition. There is a negative stigma at times which causes people not to share or revel their feelings.Second, there is help. Depression is one of the most treatable emotional conditions. Coming to this workshop is already a first step.
Have students take out a piece of paper.“Now lets see what depression means to you.”Refer to slide: How would you know you are feeling depressed?Get answers from students. Make a list on the board. Go to next slide.
Slide firstThen: **These are common symptoms but depression is a complex condition, and many people experience a combination of symptoms, not just an unpleasant feeling.
Intro: Some of the symptoms are similar to times when we feel “blue” and we all feel blue from time to time but when does it become more depression?(Refer to slide)Depression is more intensely painfulDepression lasts longerDepression interferes with day-to-day functioningDepression is a destructive emotion (unlike grief, which is painful, but is an emotional experience that leads to healing)Depression typically is more than just a painful emotional feeling. Depression represents a syndrome (cluster of symptoms) often involving problems in social interaction, behavior, thinking and biological functioning.
Intro: The first step is to understand the nature of your problem – you will feel less scared and less confused and will be in a position to make better informed choices about treatment. Depressions are not all alike and treatments vary.Let’s look at the 3 subtypes of Clinical Depression…(Refer to slide)
Psychological depressions: Defined in 2 ways – (Bullet point #1) One: triggered by psychological or emotional events (ex. Woman’s husband announces that he is going to get a divorce and in response the woman becomes depressed. She can understand her feelings because it makes sense to her that she feels sad in response to the breakup of her marriage.In this example there was a specific, painful, stressful event (divorce).Some situational triggers may also be more obscure or ill-defined. (Ex. A married man who has experienced a gradually developing emotional distance in his marriage. His wife is more detached and less affectionate. This was not a sudden event, but represents a loss all the same. As often happens in such instances, he may become aware of “something missing” in his relationship, and this may trigger a depression.Whether its obvious or not, there is a change in the life situation – relationships, lifestyle, or job – that acts as a trigger. (Bullet point #2)Two: The symptoms are exclusively psychological/emotional. Biological functioning is relatively unaffected.
Symptoms: (ask students what they think the symptoms consist of) Sadness and despair – (feelings of emptiness, disappointment, gloom, feeling “down” or “blue”. Heaviness – especially in the pit of the stomach. Literal “heartach” are physical aspects of this symptom. Irritability - 40% of people with depression do not really feel sad rather feel very irritable and easily frustrated. Frustrations feel overwhelming and create outburst. Low self-esteem – feelings of worthlessness, inadequacy, lack of self-confidence, and self-hatred. “I can’t do it,” “I’m no good” and I never do anything right”. Typically value other people above themselves, and usually defer to others’ opinions and guidance. Sometimes the feelings are temporary – perhaps in relation to losing a job or relationships – but often they are a lifelong burden.Apathy – lack of motivation to do things, social withdrawal, decreased level of activity, and/or restriction of life activities. This symptom can, in itself lead to more serious problems in a sort of depressive vicious cycle. Ex.” What’s the use, I just don’t feel like going out and being with others.” Yet failure to engage in social or recreational activities eventually leads to life’s becoming more and more void of enjoyable, meaningful activities. Interpersonal problems – sensitive to criticism or rejection. Feel uncomfortable or inadequate around other people or experience increased feelings of loneliness. May not feel okay to be assertive. Guilt feelings – Guilt is a feeling that contains not only regret or remorse,but also a belief that “I am a bad person.” It is this belief that in a “badness of self” that makes guilt a painful and destructive emotion. Negative thinking – cognitive distortions is used to refer to a tendency to think in negative and pessimistic ways. (cognitions are thoughts and perceptions). Distortions or errors in thinking and perceiving are seen in almost all types of depression. As a person beginnings to feel depressed, thoughts and perceptions become extremely negative and pessimistic. Not only a symptoms of depression but a major cause of depression and in fact are probably the most potent factor that prolongs and intensifies depression.Suicidal thoughts – thoughts about suicide are extremely common in depression. Although most people who think about suicide do not commit suicide, never the less, suicidal ideas must always be taken seriously. Most of the time, suicidal ideas reflect a view of the future which is colored by excessive pessimism and a sense of hopelessness.
Intro:Second type of Clinical Depression is Biological depressions(Refer to slide)Triggered by some type of physical (physiological) event within the body, rather than a response to life changes or painful experiences. Seem to “come out of the blue” and often leave the affected person perplexed: “I can’t understand why I feel so bad…things have been fine in my life…it makes no sense.” They also feel psychological and emotional symptoms, but there are often a host of physical symptoms caused by chemical malfunctions in the nervous and hormonal systems.
Sleep disturbances – insomnia is common but theses are some sleep problems that are specific to depression.Early morning awakening (waking up two or more hours before you would normally awaken, and being unable to return to sleep.Middle insomnia (waking up frequently during the night, but generally able to go back to sleep. Feel exhausted the following day.Hypersomnia: excessive oversleeping.Poor quality sleep: sleep eight or more hours, but during the day feel fatigued and exhausted. Appetite disturbances – Excessive increase in or loss of appetite with a corresponding weight gain or loss. Generally appetite loss is considered to be more indicative of biological depression.Loss of sex drive – biologically-based reduction in sex drive or interest.Need to differentiate between result of marital problems vs. biological issues. Fatigue and decreased energy – feel exhausted and sleeping doesn’t help. Can be primary or secondary to sleep disturbance.Inability to experience pleasure (anhedonia) – loss of a zest for life can be due to psychological issues but also chemical.Family history of depression suicide, eating disorders or alcholism. – biological depression tends to run in families.
Intro: The 3rd subtype of clinical depression is Mixed type…(Refer to slide)
Intro: Besides the psychological and biological symptoms we covered earlier so additional symptoms they experience are…(Refer to slide)Poor concentration and poor recent memory – Depression and stress are the most common causes for poor memory and concentration difficulties. Hypochondria: excessive concern with one’s healthDrug/Alcohol abuse – represent attempts to soothe the pain of depression. Alcohol abuse can also cause severe depressions.Excessive emotional sensitivity (including anger and irritability) – Overwhelming, intense surge or feelings (tearfulness irritability) in response to minor frustrations.Pronounced mood swings – experience severe mood swings, vacillating from depression to inappropriate euphoria (mania). = bipolar Panic attacks – very sudden, intense episodes of severe physical and emotional distress that are characterized by some or all of the following signs and symptoms: rapid heart rate, shortness of breath, faintness, dizziness, tingling in the fingers and toes, sometimes chest pains, a sense of anger or impending doom, panicky feelings/loss of control. Lasts 5-10 min. Not triggered by specific stressful event but rather comes out of the blue. 50% of people with panic disorder are also depressed. The importance in making distinctions between the 3 types of depression has to do with treatment. Biological and mixed type tend to respond well to treatment with anti-depressant medications (approx. 70-80% of properly diagnosed biological and mixed depression patients treated with anti-depressant medications show a good clinical response). Biological – just medsMixed – meds and therapyPsycho – therapy
Intro: Here are 3 vignettes…which subtype of clinical depression do you feel they present with?Psychological Depression
(slide) Now that you are familiar with the major signs and symptoms of depression it will be helpful to complete the self-diagnosis checklist. (Pass out checklist)This is key since a depressed person is less likely to be aware of positive changes they may be making since they tend to view themselves negatively.
Intro: Assume for a minute that two people are going to be in a race in which they must run barefoot across a gravel parking lot. Further assume that one of the racers already has blisters on his feet before the race begins. The race may be painful for both, but the person with pre-existing injuries will experience a lot more pain. In a similar fashion, it has been show that a number of emotionally damaging early life experiences can set the stage for greatly increased risk of depression in adult life. These examples will help us see why when two people are exposed to the exact same stressful condition, one person may feel bad but cope well, while the other becomes depressed.(Slide)Early losses:Young children are especially sensitive to the loss of loved ones. A parent may be lost through death, divorce or marital separation, jobs which require the parent to be gone for prolonged periods of time, and serious illness requiring long periods of hospitalization, detached parents.At times, a child is unwanted and unloved, or extremely stressful family circumstances result in parental harshness or rejection. These feelings of loss result in 3 main problems that might continue throughout adult life:Difficulties with intimacy: To become attached to and then to lose a parent can cause a child to become extremely cautious about getting emotionally close to anyone again. Such children may inwardly long for closeness, but harbor deep fears of rejection and loss and thus never allow themselves to feel truly close again. This inner sense of longing for love and emotional isolation can increase the likelihood of depression. Anxiety and fear: Children need to have parents to provide a sense of basic safety and security in the world. Losses often leave children feeling quite insecure and afraid.Profound sadness and grief: It is remarkable how fears of intimacy, insecurity, or sadness can continue deep inside a person years and years after the grievous event occurred.Such children are at very high risk for developing strong reactions to losses experienced later in life. When this happens, the present day loss touches a deep unhealed wounds from the past. Refer back to slide.
(Slide)Pervasively harsh atmosphereAll parents from time to time lose their tempers; all parents occasionally are insensitive; all parents make mistakes that hurt their children. But occasional mistakes do not leave deep wounds. Parents just need to be “good enough” being where the majority of experience are positive or even neutral. After all no one is perfect.In contrast is the pervasively harsh atmosphere found in all too many homes. (slide)Physical abuse is a part of the picture. Expressed attitude of “you are worthless, you are not wanted, you are stupid and inadequate” that parents give to children. I recently saw a father in a local grocery store shake his son and say “ you’re just a piece of shit” This is a profoundly damaging message to his boy. It undercuts his basic worth as a person.(slide)Adulthood:
(slide)Lack of support for growth: Children need protection and nurturing, but they also need encouragement to grow. At times, parents do not support growth.How? some parents hang on to their babies. When child tries to be more independent the parent may feel hurt, upset and rejected. (back to slide)So some parents will continue to perceive the child as helpless and to do everything for the child. It may be hard for them to see their child make mistakes. Child will develop sense that they cannot do things and not have confidence in themselves. This can leave them on shaking ground and afraid to do things. Such people may grow up needing constant help from others. Parents can also affront growth by ridiculing and belittling the child when they start to do things independently. Ex.Children are subjected to perfectionistic demands. A child may do her best, but “it isn’t good enough”. Straight A’s earn the parent comment “why weren’t they A plusses?” Again as the child is moving toward self-expression, the message is “your work isn’t good enough”. (slide)These messages sink in and form the core of later feelings of low self-esteem.
Child abuse and molestation: The emotional trauma of physical and sexual abuse is profound. Such treatment, especially by parents, damages a child in a number of ways.(back to slide)With sexual molestation – feel that they are to blame; at some level they come to believe: “it was my fault, I’m bad, dirty, disgusting.”
Intro: As we saw, early childhood traumas certainly make it more likely that a person will become depressed. However, depression can strike even without such predisposing risk factors. Not all life changes result in depression, of course, but there are a number of common stressors that may kindle its onset.(slide)Interpersonal losses:Number #1 trigger for depression.Ex. Death, marital separation and divorce, children moving away from home, being rejected by a friend or lover. These are not uncommon. In US, each year, approximately 1,000,000 divorces are final, 8,000,000 people loase a loved one to death, and 800,000 of us become widows and widowers (1984)Losses typically result in grief – a painful experience, but one that eventually leads to emotional recovery for most of us.As much as 25 % or people experiencing significant losses will become clinically depressed. One of the many misconceptions is how soon someone should “get over” a death or divorce – a few months. But studies have shown that it is often much longer than most people suspect.
Intro: Grieving is a normal human process and is essential for us to go through in times of loss. There are 3 phases of the grieving process. 3 phases of grieving process:(slide)phase 1: Initial shock – numbness, intense grieving, or a vacillation between emotional pain and numbness. Phase 2: grieving period per se, during which there are frequent periods of intense sadness and loneliness and the person may feel that “life is totally different”. This period is generally 2 years for death of parent, four years for marital separation/divorce, four to 6 years for death of a spouse, and 8-10 years for death of a child. Of course this may vary from person to person. Phase 3: eventual resolution. Even with resolution the griever is no “over it”. In fact, most people will continue to have times of painful remembering for years to come. Yet resolution may be assumed when the intensely painful surges of sadness have subsided or are much less frequent, and life feels “normal” again.
(slide)Existential losses: Hearing about the death of someone (not immediate). These losses force us to face very difficult questions about the meaning of our lives, our mortality, our basic satisfaction with life. One of the main existential concerns that people commonly encounter is disillusionment or loss of a dream. Most of us have hopes and dreams some well known to us and some unconscious. Many times the reality of life does not match what one longs for inwardly. It is not unusual for a person to, in a sense, wake up one day and be struck with the painful awareness that “I’m not happy” in a relationships or a job. People often go to great lengths to maintain hope even in the face of disappointing realities. Hope is not bad. Sometimes it can help us get through difficult times but sometimes it can blind us. People are able to ward off more painful feelings of loss by maintaining hope, but at some point the bubble popped. It was the eventual awareness of the profound disappointment that triggered a depression. (return to slide)2nd concern: recognition that “I won’t live forever”. This acute awareness of “time running out” may provoke not only worries about the future but also grief about the life that has been empty, disappointing, or lacking in meaningfulness.
(slide) Events that lower self-esteem:Ex. Personal failures such as failing to receive a promotion, personal rejections and criticisms, and making mistakes. Physical disease: Illness can create serious emotional distress. In some cases physical disease results in intense, daily pain, diminishing the quality of life and making it hard to experience moments of joy. Physical illnesses not only result in pain and sometimes fear of an uncertain future, but also may change a person’s life in ways which result in depression. Prolonged stress: Stress in general does not cause depression. In fact, people often are able to take on a number of stressful tasks and feel “okay.” The key appears to be how you perceive yourself in the face of stressful situations.If you start to become overwhelmed or unable to cope with mounting pressures, your self-perception can change. It is probably the belief that “I can’t handle this. I’m not in control. I’m totally overwhelmed” that triggers depression. When attempts to master stressful situations are inadequate, you may start to feel powerless, helpless, or out of control. Exposure to numerous or prolonged stressors, “plus” a self-perception of helplessness can set off a depressive reaction. Closing of section: It is clear that many human experiences can set the stage for or actually initiate depression. No wonder depression is such a common condition. You can take an important step in combating your depression by gaining some awareness of the causes of your depression is to talk about yourself, your feeling, your past and recent events with another person. The value in talking with another person about your life is two-fold. First, it helps to unravel the mystery and to make sense out of life experiences. Second, to quote a common saying, “Pain that is shared is easier to bear.”
WHAT CAUSES DEPRESSION?---BIOLOGICAL FACTORS Intro:Two structures in the brain that play a major role in our discussion of depression are the hypothalamus and the limbic system.(slide)Hypothalamus – is the control center for numerous bodily systems(the hormonal system and the immune system) and physical activities (controls or influences sleep cycles, appetite, sexual drives and the ability to experience pleasure). Adjacent to the hypothalamus are the various structures of the limbic system, “the emotional brain” because it is the seat of human emotions. 5 major causes or triggers for chemical malfunctions:medication side effectsChronic drug and/or alcohol abusePhysical illnessHormonal changesStress inducedEndogenous depression – come up for no apparent reasonBipolar –. Seasonal affective - We will explore these later today
Intro: Depression can come in various forms. Here are a few types of diagnosis for depression (Slide)Major depression:depressed moodloss of interest or pleasuresignificant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gaininsomnia or hypersomnia nearly every daypsychomotor agitation or retardation nearly every day fatigue or loss of energy nearly every dayfeelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)diminished ability to think or concentrate, or indecisiveness, nearly every day recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicideBipolar DisorderA mood disorder in which mood alternates between two extreme poles (elation or manic and depression).In the manic phase, the person may show excessive excitement or silliness, engage in risky behaviors, experience a flight of ideas and speak very rapidlyIn the depression phase, people have a downcast mood, often sleep more than usual, and feel lethargic.In order to avoid the depressive phase, some people suffer from bipolar disorder may attempt suicide when the mood shifts from elation towards depression.SAD: depressive condition to be cause by changes in the amount of sunlight in which one is exposed. Many people seem to have mild mood changes when it is cloudy outside; for others, gray skies and reduced sunlight can trigger very severe biological depressions. Usually during winter months. Treatment is light therapy – daily exposure to bright lights for 1 to 2 hours a day during the winter months. DysthymiaType of low grade chronic depression that often begins in childhood or adolescence and can last a lifetime – “minor depression”. Affects 3% of the population and results in daily experience of low self-esteem, low energy, lack of motivation, negative thinking and decreased sense of aliveness. Dual diagnosis – high rates of dual diagnosis “substance abuse/dependence coupled with Depressive diagnosis. When depression or other mental illness is coexistent with alcohol or drug abuse this is known as "dual diagnosis". If the abuse is a result of the mental illness, it may also be referred to as "self-medication", meaning that the person is using the drug as a means of coping with the symptoms of their illness.
Intro: A common symptom of depression is suicide.(slide)
Intro: Adverse life events in combination with other strong risk factors, such as depression may lead to suicide. Here are some strong risk factors for suicide:(slide)One ore more diagnosable mental or substance abuse disordersImpulsivityAdverse life eventsFamily history of mental or substance abuse disorderFamily history of suicideFamily violence, including physical or sexual abusePrior suicide attemptFirearm in the homeIncarcerationExposure to suicidal behavior of others, including family, peers, or in the news or fiction stories.Closing:It’s also important to note that many people experience one or more risk factors and are not suicidal. Suicidal behavior is complex.
Intro: Strongest risk factors for attempted suicide in adults and youth.
Pass out handout(slide)Always take suicidal comments very seriously.Try not to act shocked: The person is already highly distressed, and if you are shocked by what is said, the person will become more distressed. Stay calm and talk with them in a matter-of-fact manner, but et help immediately. If they are at a high risk, get help immediately. Call 911, 1-800-suicide or 1800-273-talk. This cannot be overemphasized, a person who is suicidal needs immediate professional help.Do not handle the situation by yourself.
(slide)While you are waiting for help to arrive:Let the person talk as much as they want to. Listen closely so that you can be as supportive as possible, and learn as much as possible about what is causing the suicidal feelings.Comfort the person with words of encouragement. Use common sense to offer words of support. Listen carefully and offer encouraging words when appropriate.Let the person know you are deeply concerned. Tell the person that you are concerned, and show them that you are concerned. Talk openly about suicide. Ask the person, “are you feeling so bad that you are thinking about suicide?”…if the answer is yes, ask “have you thought about how you would do it?” If the answer is yes, ask “have you thought about when you would do it?”There are those four important questions in abbreviated form. You need to know as much as possible about what is going on in the person’s mind. The more planning that someone has put into a suicide the greater the risk.Don’t be judgmental. Do not invalidate anything that the person says or feelsBe careful of the statements you make.You don’t want them to feel any worse than he or she already does.Let the person express emotion in the way that he or she wants. Allow the person to cry, yell, swear and do what is necessary to release the emotion. However do not allow the person to become violent or harm himself or herself. (slide)After the person has received help and is no longer critically suicidal, help the person make an appointment with a medical doctor and a therapistFollow up on the person on a regular basis
Intro:Now that we have discussed what depression is, what causes depression, and what the types of depression are we will now look at some strategies to cope with depression. We all have felt depressed once in our lives. Let’s do an activity to self-reflect on things that can make us feel depressed. HOMEWORK Project: What Makes Me Depressed?Draw a line down the middle of a piece of paper. Label the left side “Others” andthe right side “Myself.” Under “Others,” list the expectations others have of youand that person’s name. Under “Myself,” list the goals and expectations youhave of yourself. Draw lines connecting the expectations that match, and put astar by those expectations that you feel are ok or realistic. Draw a heavy blackline through the expectations you don’t like, and then answer the followingquestions:
Intro: Another major factor in influencing depression is our self-esteem. In the past workshop on Self-esteem, we discussed how negative thoughts or in this case cognitive distortions impacts the way we view ourselves. The two paths of cognitive response to a painful event are summarized above. (slide)You may ask yourself, why would anyone do something that causes pain and blocks healing? The answer is that almost no one would if these were a conscious act. Most people are not aware that they are making cognitive distortions, however. Such thinking is not a conscious, willful act, but rather, such thoughts and perceptions pass through a person’s mind in a very “automatic” fashion. This process is usually not in one’s awareness and is thus beyond conscious control. It happens to everyone…it has nothing to do with intellect.
Intro: Often our number one enemy is Negative Thinking. Simply being aware of this is not enough to stop the process. We need to take some specific steps that will allow you to actively combat the problem.(pass out handout on negative thinking)(slide)What are the types of cognitive distortions?Negative predictions – ex. A Single man asks a woman out for a date and is turned down. He thinks, “I’m never going to ever find anyone who wants to be with me.”A depressed woman thinks, “I’ve been depressed for months. I’m never going to get over this…nothing will ever get me out of this depression”In both ex, the result is an increased sense of despair and hopelessness. All or nothing thinking, tendency to jump to broad, over-generalized conclusions about yourself or reality. Ex. A woman has just turned in a report at work and her boss criticized the report. She concludes, “I can’t do anything right”. The reality is that she does many things right, in fact during the past week she has completed five other reports that were well done, but she focuses on the current criticism and arrives at the inaccurate and over-generalized conclusion, “I can’t do anything right”.Jumping to conclusions: tendency to conclude the worst in the absence of substantial evidence. Ex. A man applies for a job and is told, “We will call you on Monday if you got the job”. By Monday noon he has not heard and he concludes, “I know I didn’t get the job”. Tunnel Vision: This is the common tendency when one is depressed to focus selectively on negative details, to dwell on them and to tune out positive aspects of a situation or yourself. Ex. A middle aged man walks by a mirror and notices his pot belly. He thinks, “I’m disgusting. No wonder women aren’t interested in me.” The fact that he is somewhat overweight may be accurate, but at the moment in front of the mirror this is what he focuses on exclusively. He sees himself as disgusting. It very well may be that he is a kind and sensitive man, attributes that he overlooks as he concludes, “I’m disgusting.” He only looks at part of himself, not the whole person. Personalizing. Tendency to assume that if something is wrong, you are at fault: an assumption that may not be accurate. As a man comes to work, he says “hello” to his boss. The boss nods his head but says nothing. The man concludes, “boy, he must be mad at me.” This may or may not be an accurate conclusion. If he does not check it out with his boss, he may worry needlessly. It’s a possibility that his boss is preoccupied or upset because of a fight he had with his wife. The point is we cannot read each other’s minds and there is a strong tendency for people who feel depressed to overreact and personalize – especially when they fear criticism or rejection. Should statements: tendency to insist that things should be a certain way. Should statements may be directed toward yourself, toward others, or toward reality. Should statements can be recognized by the use of the words such as: should, shouldn’t, must, have to, and ought to. Ex. “I have to do an exceptional job at work, or I feel awful”“He shouldn’t have left me. I was good to him…I gave my whole life to him!”In each instance there is an insistence that things be a certain way. Should statements always have the effect of intensifying painful emotions; they never reduce misery or change situations.These each result in us having extremely negative and pessimistic views of oneself, current situations, and the future and intensifies emotional pain.
(slide)Being aware: (slide then additional information) An important and effective method of becoming aware of cognitions involves using feelings as signals or cues. Here’s a step you can put into action and next time you notice an unpleasant feeling. As soon as you notice such a feeling – ex. Sadness or frustration – use this emotion to let you know, “Okay something is going on in my mind.” Then ask yourself one or more of the following questions:“What is going through my mind right now?” “What am I thinking?” “What am I telling myself?” “What am I perceiving about the situation that triggered this feeling?”This is a very important step.Challenging your distortion: (slide then additional information) Get a piece of paper and draw a line down the middle. After you ask yourself, “What is going through my mind?” jot down all thoughts, word for word, on the left hand side of the sheet. The next step is to look at the thoughts, and ask these questions: “does this sound like a cognitive distortion?” and “is this thought accurate and realistic?” It is better to write it down than to do it in your mind because it makes the process more concrete and conscious.Ex. If friends are late picking you up at airport, Automatic thought: “They are not coming…maybe they’ve been in a bad car accident” Realistic response: “There is no way to know if there has been an accident…there are many reasons that they may be late.”Give yourself permission to have and to express human feelings.People often attempt to deny pain. There is nothing more human to cry if you have lost a loved one; nothing more natural than to feel disappointment if you have failed at some important task, and nothing more understandable than to feel angry if someone hurts you or uses you. The open expression of feelings, when not clouded by cognitive distortions is not only natural and human but is also tremendously important. Honest grieving and feeling, even though sometimes very painful, promotes eventual emotional healing.
Intro: Lets try this technique. Ex. If friends are late picking you up at airport, Automatic thought: “They are not coming…maybe they’ve been in a bad car accident” Realistic response: “There is no way to know if there has been an accident…there are many reasons that they may be late.”
Intro: Here are some additional self-help techniques that have been shown to help individuals who are feeling depressed. (Slide)Positive daily activity: (slide) write down everything you do, even small things. This is good cause many people who are depressed tend to overlook or minimize their accomplishments. Such a person may look at the end of the day and feel that it was a waste. This increases feelings of low self-esteem. An activity diary can help present a more realistic view of events.When recording major events of the day: record the following types of activities in particular: tasks completed (or progress made towards completion), positive events, such as receiving a compliment, have a nice lunch with a friend, getting a letter, feeling good about a job well done, and mastery of experiences. Works best if you keep it simples and easy. Then review the list at the end of the day. (slide)Daily mood rating chart: (pass out handout) ppl who are depressed tend to remember the negative feelings and events. This type of memory will only make a person feel more despair and pessimism. The fact is that even very depressed people are not 100% depressed all the time.A number of studies have shown that simply tracking and rating one’s moods on a daily basis has an effect of decreasing depression.Place a copy of the chart by your bedside table and each night take a few minutes to review the day. Ask yourself “Overall, how did I feel today?” and then rate your feelings on a scale of from plus 7 (extremely happy day) to minus 7 (extremely unhappy day). Most people will notice that there is a good deal of change in mood from day to day.(slide)Staying active and avoiding the “apathy cycle”When people experience grief or depression, a common reaction is to withdraw. They often limit their social and recreational activities, withdraw from meaningful involvement with others, and physically shut down. A part of this reaction is probably a natural desire to be alone with one’s pain. Often it is difficult or embarrassing to be around others during times of emotional distress. Some withdrawal is appropriate and normal, however marked or prolonged withdrawal can set the stage for many problems that tend to make depression worse. The apathy cycle: “if you start avoiding people they will respond by avoiding you”. They will think you will want to be left alone. It becomes a vicious cycle.Often the apathy cycle is triggered by a belief or conclusion, there are 3 primary conclusions that can set this process in motion:People don’t want to be around meIf I’m around others I wont have anything to say. I’ll be a bore.I feel so exhausted. What is very helpful at this critical moment is to say to yourself: “just do it”. It may be helpful to write these words on a index or business care and at moments of low motivation or apathy, get it out and read them. Keep in mind, “I don’t have to feel motivated. Just get moving and it will feel easier.” (slide) Building a support systemEnlist the help of a friend or relative..someone you trust.“I’ve been depressed lately and one way this has affected me is that I’m getting withdrawn. I’m not getting out and about. I know if I can push myself to get out doing things on the weekend, I will feel better. But, I need your help” When you have committed yourself to this plan, you will probably feel some degree of obligation to your friend or relative. This helps.
A pervasive sense of despair or sadness with absolutely no times when you are able to experience pleasureSevere disruption in personal relationshipsInability to workPersistent and strong suicidal ideas, or if you have made a suicide planBiological symptoms of depression such as significant sleep disturbance or weight loss.Profound hopelessness or apathy
Cognitive – How the people view the world when they’re depressed the the kind of thinking they have.GestaltThey focus on the “here and now” and not on th past. Goal is to create “awareness”. They feel that the answers in today’s issues must be treated in the present context.Says that sum of the whole is equal to the sum of tis parts. In other words, you have to connect all the little parts of your life together before you have a “whole person”, you cannot leave anything undone. They will focus on what is causing your depression, from work, school, spuses kids, social life, mental processes and so on.In therapy they will focus on observations on a person’s breathing and physical posture.Explores clients interactions with therapist.The goal is for clients to become aware of what they are doing, how they are doing it, and how they can change themselves, and at the same time, to learn to accept and value themselves.Psychodynamic – long term treatment (can take up to 2 years). Therapist keeps his own personality out of the picture (blank canvas) where the client transfers their feelings onto the therapist. Explores unresolved unconscious conflicts they may have from past.Electroconvulsive therapy – controversial psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect.
Video “Depression out of the Shadows” Ch 7.
Ending: Revisit your Beck inventory results to help you gauge what type of treatment you should explore if applicable.
COUN 107: Coping with Depression February 20, 2010 8:30am-4:30pm Marisa Mariano, MFT
“Everybody Hurts” - REM http://www.youtube.com/watch?v=ijZRCIrTgQc On a piece of paper, do a free write. Write down the words, images, thoughts that came to mind while listening to this song. What are some of the thoughts that go in your mind then you feel “blue”/”down”?
Objectives Upon completion of this course you will be able to: Evaluate the difference between feeling “blue” and depression Comprehend the various types of depression Be familiar with some self-help techniques for managing depression
Agenda 8:30-8:45 Attendance/Intro/community agreements 8:45-10:30 Class 10:30-10:45 Break 10:45-12:30 Class 12:30-1:30 Lunch 1:30-3:00 Class 3:00-3:15 Break 3:15-4:15 Class 4:15-4:30 Closing
Community Agreements Confidentiality Step-up, step back Respect (agree to disagree) One mic
FACT OR MYTH? “Depression is hurtful but not a major medical condition.” MYTH Depression isn’t simply a temporary case of “the blues”. It’s a common, serious medical condition that can disrupt ones’ daily functioning.
FACT OR MYTH? “If your parent and grandparent had depression, you’re sure to get it eventually.” Myth Because depression can run in families, scientists suspect that genes play a role. You’re 3 times more likely to develop depression if your parents suffered depression. But it’s not inevitable that you’ll get the illness, too. Scientists believe the risk of developing depression results from the combination of genetic, biochemical, psychological and environmental factors.
FACT OR MYTH? “Only emotionally troubled people become depressed.” MYTH Depression affects people from all walks of life, not just people with previous emotional troubles. Depression can strike after the loss of a loved one, trauma, or other stressful situations like the loss of a job.
FACT OR MYTH? “Most people with depression never go to a mental health professional.” FACT Only 39% of people with severe depression see a mental health professional. People with depression often see their primary care doctor. Also, many depressed patients remain undiagnosed or undertreated. Some cases of depression are tough to treat. But the vast majority of cases are highly treatable with antidepressants and talk therapy. The earlier the treatment begins, the more effective it is.
FACT OR MYTH? “Depression is most common in elderly people.” MYTH People assume the elderly suffer depression most often. In fact, middle-aged people 40-59 have the highest rates of depression. Depression is not a normal part of aging. However, ill health, medication side effects, social isolation, and financial troubles can trigger depression in elderly people. Older people belong to a generation that often feels ashamed to admit to feelings of sadness and grief. But it’s crucial that they seek help, especially because white men 85 and older have the highest suicide rate.
FACT OR MYTH? “Depression causes physical pain.” FACT Depression causes emotional symptoms such as anxiety, irritability , and hopelessness. But it can also cause physical symptoms such as chest pain, queasy or nauseated sensations, dizziness or lightheadedness, chest pain, sleep problems, exhaustion and changes in weight and appetite.
FACT OR MYTH? “Talking about depression only makes it worse.” MYTH Different types of psychotherapy, or talk therapy, have been proven effective in treating depression. For example, cognitive behavioral therapy (CBT) teaches people new ways of thinking to replace negative thoughts and behaviors that contribute to depression. In another approach, interpersonal therapy (IPT) helps people to understand troubled relationships and find ways to work through the difficulties.
FACT OR MYTH? “Being optimistic can cure depression.” MYTH Depression is debilitating. Most people with the disorder will require treatment to get better. Few can will themselves to get well through positive thinking. Depressed people may need medication to normalize brain chemicals.
“Did you know…” 1 out of 5 people will experience severe clinical depression at some point in their lives. In 1 out of 15, the depression will be so severe as to warrant hospitalization. The suicide rate for individuals experiencing repeated major clinical depressions is about 15%. In some types of depression there are hormonal changes that occur which can profoundly interfere with the functioning of the immune system. The result is that the person is less able to ward off illness and is at higher risk for health problems.
Brainstorm On a piece of paper respond to, “I feel depressed…”
Common Symptoms Sadness, despair, sense of loss, emptiness, feeling blue (the kinds of feelings most people experience when a loved one dies). Apathy, indifference, low or no motivation, fatigue Inability to experience excitement or pleasure, a loss of a zest for life Increased sensitivity to criticism or rejection; feelings are easily hurt Low self-esteem, lack of confidence, feeling inadequate; Irritability, easy frustration, anger Guilty feelings, self-blame, self-hatred Feelings of hopelessness and/or helplessness.
Feeling “blue” vs. depression 5 basic ways that differentiate them: Depression is more intensely painful Depression lasts longer Depression interferes with day-to-day functioning Depression is a destructive emotion Depression typically is more than just a painful emotional feeling.
3 subtypes of Clinical Depression Psychological – emotional reactions to losses and disappointments Biological – depressions that in many respects are true medical illnesses Mixed type – blend of emotional and physical reactions
Psychological depressions Defined in 2 ways: 1)Triggered by psychological or emotional events ** Whether it is obvious or not, there is a change in the life situation – relationships, lifestyle, or job – that acts as a trigger. The symptoms are exclusively psychological/emotional. Biological functioning is relatively unaffected.
Symptoms of psychological depression Sadness and despair Irritability Low self-esteem Apathy Interpersonal problems Guilt feelings Negative thinking Suicidal thoughts
Biological Depressions Triggered by some type of physical (physiological) event within the body, rather than a response to life changes or painful experiences. Seem to be more “out of the blue”
Physical symptoms of depression Sleep disturbances Early morning awakening Middle insomnia Hypersomnia Poor quality sleep Appetite disturbances Loss of sex drive Fatigue and decreased energy Inability to experience pleasure (anhedonia) Family history of depression suicide, eating disorders or alcholism
Mixed type: Psychological depressions with biological symptoms This group represents a very large number or people experiencing clinical depression. It has a psychological trigger, but in these cases, the person experiences both emotional and physical symptoms.
Additional symptoms – Mixed type Poor concentration and poor recent memory Hypochondria Drug/Alcohol abuse Excessive emotional sensitivity (including anger and irritability) Pronounced mood swings Panic attacks
Which subtype does Mike present with? Mike had his heart set on a promotion, after two years on the job. He had worked heard, and felt he was doing well. Last month a position opened up, but another employee – one who had been with the company only six months – was given the job. It was tremendously upsetting for Mike to be passed over for the promotion. During the past few weeks he has felt preoccupied with feelings of inadequacy and low self-esteem. He often thinks to himself: “I’m never going to get a promotion. Obviously I just don’t have what it takes.” A part of his reaction to this event has been to progressively withdraw from life. He has turned down offers to go out to dinner. He prefers to go home at night, have a drink, and just go to bed. Most of the time he feel sad and “unmotivated.” Every now and then, he entertains fleeting ideas of suicide.
Which subtype does Eve present with? Eve is a thirty-two-year-old married woman who recently learned that her thirty-four-year-old husband has cancer. Since hearing this news two weeks ago, she has had periods of intense sadness and crying spells, frequent thoughts about his illness, and fears about being alone, should he die. She also is plagued with feelings of guilt and self-blame. She feels guilty for having taken him for granted during the past few years. In addition, she also has had noticeable loss of sexual desire and has what she describes as “terrible sleep,” waking up a dozen times during each night.
Which subtype does Joel present with? Joel is a fifty-two-year-old lab technician, married with two grown children. He is considered to be an extremely hard-working man and is well liked. Last month, for no apparent reason, Joel started to experience some gradual changes. Although normally quite sociable, he began to feel uncomfortable being around people. He told his wife that he didn’t’ know why, but would prefer to cancel their social engagement. At work he seemed to withdraw and be especially quiet. Several people asked him if he was feeling sick. He said, “Yea, kinda.” He started to notice that food didn’t taste right, and his appetite dropped off. In the past three weeks, he has lost four pounds. Also he has started to wake up at 4:00am and is unable to return to sleep. This sleep pattern is quite unusual for Joel.
Single episodes versus reoccurring episodes 2/3 of major depression episodes are likely to recur. While some people function normally between episodes, many continue to experience persistent, low-grade depressive symptoms. Self-diagnosis checklist Used for 3 purposes 1) to help you determine just how depressed you really are; 2) to self-diagnose your possible need for medication treatment; and most importantly 3) as a way to monitor change over time
What causes depression? – Personal history Early losses 3 main problems in adulthood: 1) Difficulties with intimacy 2) Anxiety and fear 3) Profound sadness and grief Note: not all losses guarantee a person will become depressed as an adult. 2 important factors 1) emotional availability of at least one other adult 2) it is very important to help a child grieve.
What causes depression? – Personal history Pervasively harsh atmosphere Physical abuse is a part of the picture. Expressed attitude of “you are worthless”, “you are not wanted”, “you are stupid and inadequate” that parents give to children. Adulthood: Such kids grow up with damaged sense of self worth. Even small failure or setbacks as adults touch on the inner painful belief.
What causes depression? – Personal history Lack of support for growth So some parents will continue to perceive the child as helpless and to do everything for the child. It may be hard for them to see their child make mistakes. Adulthood: Child will develop sense that they cannot do things and not have confidence in themselves. This can leave them on shaking ground and afraid to do things. Such people may grow up needing constant help from others. Parents can also affront growth by ridiculing and belittling the child when they start to do things independently. Adulthood: These messages sink in and form the core of later feelings of low self-esteem. Tend to be perfectionists.
What causes depression – Personal History Child abuse and molestation The emotional trauma of physical and sexual abuse is profound. With sexual molestation – feel that they are to blame; at some level they come to believe: “it was my fault, I’m bad, dirty, disgusting.”
What causes depression – current life events Interpersonal losses Number #1 trigger for depression. Ex. Death, marital separation and divorce, children moving away from home, being rejected by a friend or lover. Losses typically result in grief – a painful experience, but one that eventually leads to emotional recovery for most of us. As much as 25 % or people experiencing significant losses will become clinically depressed. One of the many misconceptions is how soon someone should “get over” a death or divorce – a few months. But studies have shown that it is often much longer than most people suspect.
3 phases of grieving process 3 phases of grieving process: phase 1: Initial shock Phase 2: grieving period Phase 3: eventual resolution
What causes depression – current life events Existential losses Hearing about the death of someone (not immediate) One of the main existential concerns that people commonly encounter is disillusionment or loss of a dream. Another concern: recognition that “I won’t live forever”.
What causes depression – current life events Events that lower self-esteem Ex. Personal failures such as failing to receive a promotion, personal rejections and criticisms, and making mistakes.
Physical disease: Illness can create serious emotional distress. Physical illnesses not only result in pain and sometimes fear of an uncertain future, but also may change a person’s life in ways which result in depression. Prolonged stress: Stress in general does not cause depression. The key appears to be how you perceive yourself in the face of stressful situations.
What causes depression – biological factors Hypothalamus and the limbic system Hypothalamus – is the control center for numerous bodily systems and physical activities.
Limbic system, “the emotional brain” because it is the seat of human emotions.
5 major causes or triggers for chemical malfunctions: medication side effects Chronic drug and/or alcohol abuse Physical illness Hormonal changes Stress induced Endogenous depression – come up for no apparent reason Bipolar Seasonal affective
Mood disorders in DSM-IV Major Depression Bipolar Disorder SAD Dysthymia Dual Diagnosis
Suicide - Statistics Up to 15% of those who are clinically depressed die by suicide. In 1997, suicide was the 8th leading cause of death in the US. The total number of suicides was approximately 30,535. In 1996 there were an estimated 500,000 suicide attempts. More than four times as many men than women die by suicide. However, women report attempting suicide about twice as often as men. The majority of suicide attempts are expressions of extreme distress that need to be addressed and not just a harmless bid for attention. A suicidal person should not be left alone and needs immediate mental health treatment.
Risk factors for Suicide One ore more diagnosable mental or substance abuse disorders Impulsivity Adverse life events Family history of mental or substance abuse disorder Family history of suicide Family violence, including physical or sexual abuse Prior suicide attempt Firearm in the home Incarceration Exposure to suicidal behavior of others, including family, peers, or in the news or fiction stories.
Strongest risk factors: Adults and youth Adults: Diagnosis of depression Alcohol abuse and/or cocaine use Separation or divorce Youth: Diagnosis of depression Alcohol or other drug use disorder Aggressive or disruptive behaviors
How to help someone who is suicidal www.suicide.org Always take suicidal comments very seriously. Try not to act shocked. If they are at a high risk, get help immediately. Do not handle the situation by yourself
How to help someone who is suicidal (continued) While waiting for help to arrive or if there is no emergency: Listen attentively to everything that the person has to say Comfort the person with words of encouragement Let the person know you are deeply concerned. If they are at high risk for suicide, do not leave them alone. Talk openly about suicide (suicidal?, method?, means?, when?) Don’t be judgmental. Be careful of the statements you make Listen, listen, listen. Be gentle, kind and understanding. Let the person express emotion in the way that he or she wants. After the person has received help and is no longer critically suicidal, help the person make an appointment with a medical doctor and a therapist Follow up on the person on a regular basis
What to do if you are feeling suicidal Call a suicide hotline 1-800-SUICIDE or 1-800-273-TALK Contact a supportive friend of family member and talk to them Call PES or 911 if you feel you are at high risk Seek professional help/treatment
Activity – What makes me depressed? Draw a line down the middle of a piece of paper. Label the left side “Others” and the right side “Myself.” Under “Others,” list the expectations others have of you and that person’s name. Under “Myself,” list the goals and expectations you have of yourself. Draw lines connecting the expectations that match, and put a star by those expectations that you feel are ok or realistic. Draw a heavy black line through the expectations you don’t like
Activity (cont’) Answer the followingquestions: 1. What things are you experiencing that are causing you to be depressed?
2. You often can’t change your circumstances, but you can change your attitude toward them. Go back to your answers for #1 and write down attitude changes that might prevent you from feeling depressed.
3. List every good thing in your life.
4. It’s ok to be sad, disappointed and depressed, but if you don’t deal with the problem, it will only get worse. Write the details of those depressing situations on a piece of scrap paper. Crumple them up and throw them away. Write on another piece of paper your plan of action to prevent depression from taking over. Do you need new friends, someone to talk to, or a change in attitude? Don’t let depression overtake you. Find someone to talk to and tell them how you are feeling.
#1 enemy: Negative Thinking What are the types of cognitive distortions? Negative Predictions All-or-none thinking Jumping to conclusions Tunnel vision Personalizing Should statements
How to change cognitive distortions? Being aware of your cognitive distortions Sense a feeling => tune into thoughts => ask the questions => find the thought behind the feeling. Challenging your distortion “How realistic is my thinking?” Identify the real facts, compare your thoughts with reality, and phrase a new, more realistic thought. Give yourself permission to have and to express human feelings
Activity on Cognitive Distortions Think about an unpleasant moment where you felt (sad, frustrated, angry) On your paper, draw a line down the middle. On the left put, “What was going through my mind?” and jot down all thoughts word for word. Look at the thoughts and ask yourself: “Does this sound like a cognitive distortion?” “Is this thought accurate and realistic?”…write your answers down. On the right column, write realistic responses next to your cognitive distortions.
Treatments – Self-help Positive daily activity diary 2 ways: write down every single thing you did or record the major events of each day. Daily mood rating chart Staying active and avoiding the “apathy cycle” Building a support system
Treatments – Self-Help (cont’) Alternative health Accupuncture Herbal supplements (St. Johns Wart) Self-help books Journals Exercise and diet Sleep Catch some rays Avoid alcohol and caffeine Music and art
When should you consult a mental health professional? When the self-help approaches are not enough and you experience: A pervasive sense of despair or sadness Severe disruption in personal relationships Inability to work Persistent and strong suicidal ideas Biological symptoms of depression Profound hopelessness or apathy
Treatments Individual Psychotherapy/Counseling Various techniques Cognitive Gestalt Psychodynamic Electroconvulsive therapy Group therapy Hospitalization
Treatments - Medication Anti-depressants Used for Major Depression Side effects Varies per person Lithium Used for Bipolar Disorder http://www.pbs.org/wgbh/takeonestep/depression/video-ch_07_vid.html?tos=vid&filetype=mov&bandwidth=_hi
Resources (on and off campus) Psych Services on campus Pyramid www.suicide.org